FIGO (The International Federation of Gynaecology and Obstetrics) has recently produced guidelines for healthcare staff on the management of pregnant women during the COVID-19 outbreak.
The guideline covers all stages of pregnancy from antenatal care, obstetric triage, intrapartum through to postpartum management and neonatal care. It also includes a section of the medical treatment of pregnant women who test positive for COVID-19.
The authors consider their recommendations as suggestions, recognising that these may need to be fine-tuned in different centres. Furthermore, they recognise that as the knowledge-base of COVID-19 changes rapidly, their guidance should be considered in light of other relevant guidance from other organisations such as the World Health Organization.
The pertinence of the guideline is that because of the physiological changes associated with pregnancy, women are predisposed to viral respiratory infections and are known to be more likely to develop severe illness after such infections. This has been highlighted in other respiratory outcomes such as the H1N1 (swine flu) outbreak in 2009, in which 5% of all H1NI-related deaths occurred in pregnant women. Fortunately and to date, the limited information that is available, has demonstrated that pregnant women diagnosed with COVID-19 survive pregnancy without any major complications.
Antenatal care
The first point of the guideline is the recommendation to reduce the number of clinic visits for low-risk women and the suggestion that staff use telephone or video calls instead. Pregnant women should self-check their blood pressure at home and provided with advice on when it would be appropriate to seek medical advice. During clinic appointment, all women should be screened for COVID-19 symptoms and any relevant exposure and attend alone if possible. When screening reveals that the woman potentially has COVID-19, the appointment should be deferred for 14 days unless there are urgent maternal or foetal reasons. The guidance also suggests that where screening identifies a likely infection and the appointment is deemed necessary, the woman should wear a mask and her appointment is considered as a priority to minimise her time at the clinic. An antenatal outpatient care algorithm is provided in the guideline as a useful resource for healthcare staff.
Obstetrical triage
When a woman attends obstetric triage or the emergency department for either obstetric or respiratory symptoms, the guideline advocates the same screening procedure as for antenatal care. As with the antenatal care guidance, a positive screened woman needs to wear a mask and be assessed in isolation. Both symptoms and vital signs and comorbidities should be assessed and COVID-19 testing considered. In the case of mild symptoms, the patient can discharged and asked to monitor symptoms, seeking further advice if symptoms worsen.
In cases where the patient has moderate disease or comorbidities and other risk factors for severe COVID-19 infection, it is advised that a more detailed assessment is undertaken.
Intrapartum management: suspected or confirmed cases
The guideline mentions that COVID-19 infection is not an indication for delivery unless there is a need to improve maternal oxygen. Suspected or confirmed cases should have their delivery in an isolated negative pressure room and the number of staff present kept to a minimum. It is advised that birthing partners are not permitted to attend. The delivery needs to be assessed on an individual basis and as with the other sections, a useful intrapartum algorithm is provided.
Postpartum and neonatal care: suspected or confirmed cases
In cases of suspected or confirmed cases, umbilical cord clamping should be performed promptly and the neonate transferred to the resuscitation area for assessment. However, the guideline recognises that there is insufficient evidence on whether delayed clamping increases the risk of infection to the new-born. Staff should continue to use PPE during the postpartum period unless or until the mother tests negative for COVID-19. The guideline states that there is a lack of evidence on the possible transmission via breastfeeding but recommends separation with attempts to express breast milk if the mother is severely ill. Again an algorithm is provided to help staff manage postpartum care.
Psychological interventions
The guideline recognises how pregnant women are at an increased risk of anxiety and depression, especially where they are considered as a suspected or even confirmed COVID-19 infection. Staff are advised to pay particular attention to the woman’s mental health and make an assessment of her sleep patterns and potential sources of anxiety and depression and even suicidal ideation.
Treating suspected/probably infected cases
Suspected, probable and confirmed cases of COVID-19 infection should be managed in isolation facilities with protective equipment. Where there is a definitive diagnosis, women should be treated in a negative pressure isolation room. However, the guidance believes that pregnant infected women with mild symptoms can remain at home provided her condition can be suitably monitored. If a woman needs to be transferred to hospital, staff are advised to wear appropriate personal protective equipment (PPE) and maintain a 2m distance from any individuals without PPE.
It is advised that fluid and electrolyte balance are maintained and symptomatic antipyretic treatment is offered. Women’s vital signs should be monitored, for example, oxygen saturation, full blood count and renal, liver function and coagulation testing regularly evaluated. In addition, foetal surveillance should be undertaken including cardiotocography (CTG) for heart rate monitoring (weeks 23–28).
Infected patients
Mild disease
This should be as for managing suspected cases above, that is, maintaining fluid and electrolyte balance and surveillance. Although recognising that there are currently no proven effective anti-viral treatments for COVID-19, the guideline suggests that if these are considered a decision should be made after consultation with a virologist. It is also recommended that women are monitored for bacterial infection (for example, blood cultures, midstream or catheterised specimen urine microscopy and culture) and that the foetus is monitored with CTG as in suspected cases above.
More severe cases
Women with more severe disease such as pneumonia should be managed in line with the American Thoracic Society guidelines for community-acquired pneumonia. The guideline notes how severe pneumonia is associated with a high maternal and perinatal mortality rate and therefore requires aggressive therapy including both supportive measures with hydration and oxygen therapy. Treatment should include appropriate antibacterial and anti-viral agents following discussion with microbiologists.
Finally, the guideline states that there is currently no evidence of vertical mother-to-baby transmission for those becoming infected in late pregnancy although this position might be modified in light of any new evidence.
Reference
1. Poon LC et al. Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals. Int J Gynaecol Obstet 2020;Apr 4 [Online ahead of print].
