What we know about on COVID19 and pregnancy-

Novel coronavirus (SARS-COV-2) is a new strain of coronavirus causing COVID-19, first identified in Wuhan City, China. Other coronavirus infections include the common cold (HCoV 229E, NL63, OC43 and HKU1), Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV).

Cases of COVID-19 globally have evidence of human to human transmission. Recently cases have appeared where there is no evidence of contact with infected people.This virus appears to spread readily, through respiratory, fomite or feco-oral methods. People are recommended to employ strict infection prevention and control (IPC) measures; guidance is available as per local Health advisories.

TRANSMISSION FROM MOTHER TO CHILD –

Two cases of possible vertical transmission (transmission from mother to baby antenatally- before delivery or intrapartum- during delivery) have been reported. In both cases, it remains unclear whether the transmission was prior to or soon after birth. Expert opinion is that the fetus is unlikely to be exposed during pregnancy. A case series published by Chen et al tested amniotic fluid, cord blood, the newborn’s throat swabs and breast milk samples from COVID-19 infected mothers and all samples tested negative for the virus. Furthermore, in a different paper by Chen et al, three placentas of infected mothers were swabbed and tested negative for the virus; and in another case series by the same team, of three infants born to symptomatic mothers tested for the coronavirus, none had positive tests.

Transmission is, therefore, most likely to be as a newborn and in another case series by the same team, of three infants born to symptomatic mothers tested for the coronavirus, none had positive tests. There is currently no evidence concerning transmission through genital fluids.

EFFECT ON THE MOTHER/SYMPTOMS-

The large majority of women will experience only mild or moderate cold/flu-like symptoms. Cough, fever and shortness of breath are other relevant symptoms. More severe symptoms such as pneumonia and marked hypoxia are widely described with COVID-19 in older people, the immunosuppressed and those with long- term conditions such as diabetes, cancer and chronic lung disease. These symptoms could occur in pregnant women so should be identified and treated promptly. At present there is one reported case of a woman with COVID-19 who was admitted to hospital at 34 weeks of pregnancy, had an emergency Caesarean section for a stillborn baby and was admitted to the intensive care unit with multiple organ dysfunction and acute respiratory distress syndrome, requiring extracorporeal membrane oxygenation. Within the general population, there is evolving evidence that there could be a set of asymptomatic individuals or those with very minor symptoms that are carrying the virus, although the incidence is unknown.

EFFECT ON THE FETUS-

There are currently no data suggesting an increased risk of miscarriage or early pregnancy loss in relation to COVID-19. Case reports from early pregnancy studies with SARS and MERS do not demonstrate a convincing relationship between infection and increased risk of miscarriage or second-trimester loss.

As there is no evidence of intrauterine fetal infection with COVID-19 it is therefore currently considered unlikely that there will be congenital effects of the virus on fetal development.

There are case reports of preterm birth in women with COVID-19, but it is unclear whether the preterm birth was always iatrogenic (brought about by a medical professional or by treatment or by treatment environment), or whether some were spontaneous. Iatrogenic delivery was predominantly for maternal indications related to the viral infection, although there was evidence of fetal compromise and pre-labour premature rupture of membrane, in at least one report.

HEALTH ADVICE FOR PREGNANT WOMEN –

As a pregnant woman, the news of the coronavirus pandemic may have caused you concern.

We would like to reiterate that the evidence we have so far is that pregnant women are still no more likely to contract the infection than the general population. And it’s high in the general populace right now. What we do know is that pregnancy, in a small proportion of women, can alter how your body handles severe viral infections. This is something that midwives and obstetricians have known for many years and are used to dealing with.

What is there is the need to restrict the spread of illness because if the number of infections was to rise sharply the number of severely infected women could rise and this could put the lives of some pregnant women in danger.*

My friendly gynaec’s take on Pregnancy and SAR CoV 2 pandemic is:

• If you get infected with COVID-19 you are still most likely to have no symptoms or a mild illness from which you will make a full recovery
• If you develop more severe symptoms or your recovery is delayed this may be a sign that you are developing a more significant chest infection that requires enhanced care, and our advice remains that if you feel your symptoms are worsening or if you are not getting better you should contact your maternity care team straight away for further information and advice.
• If you are well at the moment and have no complications in any past pregnancies and no conditions like diabetes, hypertension, immunosuppression, kidney disease, the following practical advice may still be helpful
  • MOST IMPORTANTLY SOCIAL DISTANCING (more accurately Physical distancing). This is a non-pharmaceutical infection prevention and control intervention implemented to avoid/decrease contact between those who are infected with a disease/pathogen and those who are not, so as to stop or slow down the rate and extent of disease transmission in a community. HOW? Keeping a distance of at least one metre in various necessary interactions and activities
  • Disinfection of surfaces to reduce fomites related spread.
  • For women working outside the house, it is preferable to take Work from Home.
  • Avoid non-essential travel. If travel is undertaken, it is preferable to use a private vehicle. If public transport is used, the distance should be maintained.
  • Avoid gatherings and functions to celebrate the 7-month milestone, which is a common cultural practice.
  • Minimize visitors from coming to meet the mother and newborn after delivery.
  • Continue to take necessary precautions like hand washing
  • Do not self medicate, approach health care in case of any respiratory symptoms like a cold, cough.
  • Defer routine visits but only after consulting with your obstetrician. Essential milestone visits such as the 12 and 19-week scans are needed. If you have a routine scan or visit due in the coming days please contact your maternity unit for advice and to agree to a plan. You will still need to attend for a visit but the appointment may change due to social distancing and the medical team due to logistical aspects in these times.
  • If you are between appointments, please wait to hear from your maternity team.
  • Women are advised to note fetal movements every day. The next visit can be at 32 weeks of pregnancy.
  • You can consult the healthcare provider telephonically or through a web platform for minor ailments and questions.
• If you have an urgent problem related to your pregnancy but not related to Coronavirus, get in touch using the same emergency contact details you already have.
• If you have symptoms of Coronavirus, contact your maternity service and they will arrange the right place and time to come for your visits. You should not attend a routine clinic.
• You will be asked to keep the number of people with you to a minimum.This will include being asked to not bring children with you to maternity appointments.
• At this time it is particularly important that you help your doctor take care of you. If you have had an appointment cancelled or delayed, and are not sure of your next contact with your doctor, please get in touch with them.

Pregnant women are a special category in terms of healthcare and are possibly more susceptible. They should therefore, follow these guidelines fastidiously. They can protect themselves by the motto “Do the Five”. The principle elements of this are:

Home	Stay at home as much as possible unless there is a medical need related to development of symptoms of infection or related to pregnancy. Routine antenatal visits are to be deferred. If there is a minor query, it can be sorted out telephonically. At present, telephonic consultations are permitted by the Medical Council of India till the situation comes under control (9). Keep the traffic of home visitors including homecare personnel, maids, and staff members to a minimum or avoid completely if possible.
Hands	Washing their hands frequently and properly with a soap and water or an alcohol-based hand rub for minimum 20 seconds
Elbow	Covering their mouth and nose with their bent elbow, handkerchief or tissue while coughing or sneezing. Then the used tissue should be disposed off immediately. This is an important component of respiratory hygiene.
Face	Avoid touching your face, eyes, nose and mouth with hands.
Space	Keep a distance of at least 1 meter from the next person outside and in the house.

Instructions for contacts, When a pregnant woman is home quarantined

The home quarantined pregnant lady should:

· Stay in a well-ventilated single-room preferably with an attached/separate toilet.

· If another family member needs to stay in the same room, it’s advisable to maintain a distance of at least 1 meter between the two.

· Needs to stay away from elderly people, pregnant women, children and persons with co-morbidities within the household.

· Restrict his/her movement within the house.

· Under no circumstances attend any social/religious gathering e.g. wedding, condolences, etc.

General health measures to be followed in quarantine include hand washing, avoiding sharing fomites, wearing a surgical mask and changing it every 6 to 8 hours with correct disposal in 1% hypochlorite solution. If symptoms appear during quarantine, the pregnant woman should contact a health facility by telephone and follow the given advice.

Family members of the pregnant woman quarantined at home should keep a distance from her at all times and avoid direct contact with her and her fomites. Disposable gloves should be used in case soiled linen has to be handled. Visitors should not be allowed. Clothes should be washed separately.

The duration of home quarantine is 14 days from the time of exposure to a confirmed case or earlier if a test is performed on a suspect case and it is negative.

Source:

*SOURCE- ROYAL COLLEGE OF OBSTETRICS AND GYNAECOLOGY ,UK ,UPDATED MARCH 18 2020

FOGSI 28/3/2020 (FEDERATION OF OBSTETRICS AND GYNAECOLOGICAL SOCIETY OF INDIA)