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In the present day scenario, arrival of a COVID-19 patient or a Person under Investigation (PUI) in a healthcare facility involves activation of a series of protocols so as to avoid, as far as possible, unnecessary exposure of other unaffected patients and staff to SARS-COV-2.

This is especially true in case of obstetric patients, which is a unique subset of patient population, since a prolonged contact of healthcare workers is expected with such women. To reduce the risk of exposure, the SARS-COV-2 positive patients and PUI for COVID-19 should be located in a restricted area of the hospital. A log of the staff that enters and exits these containment areas should be maintained, to enable systematic tracking of potential exposure. Hospital visitors should be restricted or eliminated for these pregnant women and they should be wearing a surgical mask at all times.

Personal Protective Equipment for Hospital Staff Involved with COVID-19 Pregnant Women

N95 masks should be used in any room, (e.g. labor and delivery room, ORs) where an aerosolizing procedure is being performed or is likely to be performed. Examples of aerosolizing procedures are cesarean deliveries, women brought to OR for management of post-partum hemorrhage, intubation, etc.

Patient Rooms

Women who test positive for SARS-COV-2 or are PUIs, should ideally be placed in an isolation room. In general, isolation rooms with droplet and contact precautions are recommended. If aerosolizing procedures are anticipated, then airborne infection isolation rooms should be used (these are single patient negative pressure rooms with a minimum of six air changes per hour).

Operation Rooms (Theaters)

Hospitals may consider specific Operation Rooms (ORs) that can be converted to negative pressure rooms and designated for cesarean deliveries of SARS-COV-2 or PUIs. Though, with proper PPEs and Patient Transfer Protocols, cesarean deliveries can still be performed in positive flow ORs. If a negative pressure OR is to be considered then there should be no open surgical instruments.

Labor and Delivery

The CDC doesn’t categorize a vaginal delivery as an aerosolizing procedure, so droplet and contact precautions are deemed adequate. During the second stage of labor there is repeated and long exhalation by the women and substantial exposure of staff to body fluids. Therefore N95 masks should be readily available for use by the staff. Each institution will have its own infection prevention guidelines regarding reuse of N95 masks and face shields.

Antepartum Medication Considerations in the Hospital Setting

Antenatal corticosteroids (ANCS) for preterm deliveries

Prolonged exposure to high dose steroids may be associated with worsening of COVID-19 patient outcomes in the general population. As of now, it is not known how this would apply to antenatal usage, considering such usage is not a prolonged one. In light of this, protocols regarding ANCS may need to be adjusted. Particular care should be exercised when considering ANCS for critically ill women in an ICU setting.

Magnesium for fetal Neuroprotection

Since Magnesium is a respiratory depressant and is handled by the kidney, its use in the antepartum setting for COVID-19 pregnancies and PUIs will be guided by the respiratory and renal status of the women. A single 4 gram bolus dose of Magnesium Sulfate may be used as an alternative to the usual dosing, in the setting of mild respiratory distress. For those women who have a more severe respiratory distress, with increasing oxygen requirements, the risk-to-benefit ratio should be considered prior to its use for fetal neuroprotection

Use of nonsteroidal anti-inflammatory drugs ( NSAIDS )

There is lack of adequate data regarding the use of NSAIDS in COVID-19 women.

Considerations regarding Procedures and Medication during Labor & Delivery

Internal Monitors

Internal Monitors such as fetal scalp electrodes may be used, considering that data, so far, doesn’t suggest maternal to fetal transmission to SARS-COV-2.

Amniotomy

This may still be used for labor management as clinically indicated.

Operative Vaginal Delivery

Data till date, on perinatal transmission of SARS-COV-2 does not preclude the use of forceps or vacuum.

Magnesium for Pre-Eclampsia / Seizure Prophylaxis

In general, for women without severe features, it is safer to avoid Magnesium for these indications.

Epidural Analgesia for Labor

This may be considered early to mitigate the risks associated with General Anesthesia in case urgent cesarean section needs to be done.

Fetal Considerations

There may be maternal hypoxia in severe cases of COVID-19 which can cause fetal hypoxemia and ultimately acidemia. Since protracted clinical course is often seen with COVID-19, the risks of prolonged fetal hypoxemia (examples stillbirth, neurologic injury) must be balanced against the risks associated with delivery at the given gestational age in the setting of rapidly worsening maternal respiratory status.

Postpartum Care

• After delivery, the neonate has to be separated from the mothers who are suffering from COVID-19 or are PUI for SARS-COV-2.
• To avoid respiratory droplet infection, the neonate should be given expressed breast milk by a caregiver and not the mother.
• Non urgent postpartum procedures, such as tubal ligation, should be postponed.
• As the new born of a COVID-19 is considered a PUI, performing a procedure such as circumcision should be made after consultation with the pediatric team. Appropriate PPE should be worn by the healthcare staff.

Healthcare Proxy for COVID-19 & PUIs Pregnant Women

These women should be encouraged to have a healthcare proxy and / or advance directive on admission to the hospital.

Ultrasound in COVID-19 Pregnancies

Society for Maternal Fetal Medicine (SMFM) has given COVID-19 Ultrasound practice suggestions (as updated on 23rd March 2020) regarding antenatal sonography in COVID-19 pregnancies.

All the patients scheduled for antenatal ultrasound should be contacted before to their visit, to check if they are suffering from COVID-19 or considered a Person under Investigation (PUI) in the last two weeks. A further inquiry should be made from the patient about the symptoms suggestive of COVID-19 disease. In case any patient is suffering from COVID-19 or is a PUI their appointment should be rescheduled.

The number of transducers on the ultrasound machines should be reduced to two, one low frequency (1-6 MHz) and one high frequency (2-9 MHz). The transvaginal probe should be kept outside the examination room. All other transducers, when not in use, should be removed and stored, especially those that are fragile and may get damaged by cleaning solutions. Examples of these are electronic and mechanical 3D probes with membrane footprints.

70% Isopropyl alcohol can be used for disinfection of most transducers. For electronic and mechanical 3D probes with membrane footprints manufacturer instructions should be followed. Transvaginal probes require a higher level of disinfection. This could be done with peroxide, peracetic acid, glutaraldehyde and orthophthalaldahyde.

As the effect of COVID-19 is studied in greater details, in the days to come, more information shall become available. This may lead to change in protocols and management of obstetric patients and the neonates.

References:

1. Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019(COVID19) in Healthcare Settings. 2020 [cited 2020 March 11]
2. Centers for Disease Control and Prevention. Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings. 2020 [cited 2020 March 11]