[10 MIN READ]
Updated: August 20, 2020
Navigating the ever-changing landscape surrounding the coronavirus pandemic is keeping everyone on their toes. Healthcare administrators and provider inboxes are packed with notifications and updates. We are all trying to sort through what is pertinent to hands-on patient care while doing our due diligence to remain up to date and well informed.
Early pandemic guidelines were based on expert opinion with little evidence to support recommendations. As the pandemic wears on and high-quality evidence becomes available, new recommendations will evolve supporting standardization of practice. While keeping current can seem daunting, it remains crucial for the safety of both you and your patients that you continue to do your best to remain knowledgeable and informed. The Centers for Disease Control (CDC) and the American College o Obstetricians and Gynecologists (ACOG) offer ongoing updates; patient handouts are available on these sites as well.
Provided here is a brief synopsis of newer updates (July/August 2020) specific to COVID and the obstetric population.
Transmission of COVID from mother to fetus – known as vertical transmission – is now being reported in the literature in France (July 2020). Transplacental transmission was cited in a woman who tested positive at 38 weeks gestation. This was very surprising since most placental samples reported have tested negative. Testing continues to advance on amniotic fluid, cord blood, breastmilk and placental samples. Recent placental studies reveal that while the virus does replicate in the placenta, key protein receptors and enzymes that allow the virus to enter cells remain negligible.
Kreis et al. are experts who have studied the human placenta. The placenta is a barrier for the fetus that protects it from maternal infections; the authors state that vertical transmission would be rare for this reason alone. Exceptions may exist with comorbidities like preeclampsia and high blood pressure or chronic inflammation in which placental circulation is already compromised. Birth outcomes remain an area that requires further investigation because COVID-infected placentas do exhibit vascular malperfusion.
Risk to Pregnant Women
While overall risk for pregnant women remains relatively low to date (lower than H1N1 infection rates for pregnant women), it was previously thought that pregnant women were not at increased risk for mortality and morbidity from COVID. However, newer information reflects that women with known respiratory infection are at a greater risk than the general population for morbidity and mortality.
The CDC has reported that COVID-positive pregnant women are at a greater risk for severe disease manifestations that require ICU admissions/mechanical ventilation than non-pregnant women. As is typical with other respiratory infections, maternal comorbidities can play into disease severity and outcomes. Additionally, pregnant patients with high BMIs and comorbidities were more likely to test COVID-positive. Therefore, infection-prevention counseling for women of all childbearing ages, both pregnant and non-pregnant, remains essential.
Furthermore, the pandemic has shown health inequities in women of color and low-income populations. African-American, Hispanic, and Native-American women are disproportionately infected; these groups are at risk for poor outcomes. ACOG has stated that these patients should be entitled to the same labor support, pain medication practices, and maternity care provided to all other patients. The full extent of health inequity remains elusive and continues to be investigated to allocate appropriate resources. Identification of barriers and challenges will be necessary to bring forth equitable care.
Risk mitigation begins with screening/testing vigilance and remains imperative to developing safety strategies. One study noted that the most frequent symptoms seen during pregnancy were:
- Cough: 53%
- Shortness of breath: 30%
- Runny nose: 10%
- Loss of taste or smell: 17%
Pregnant women were also more likely to report nausea and vomiting, but less likely to report headache, fever, chills, sore throat, abdominal pain, diarrhea and muscle aches.
The virus remains detectable on a swab test for about 3 weeks after acute infection; then the virus is nondetectable and the person will test negative. In some rare cases, viral shedding was reported up to 83-120 days after symptom resolution.
In order to optimize health and prevent infection, ACOG has proposed the following:
- Do not skip or miss any prenatal appointments; maximize the use of telemedicine appointments as appropriate.
- Wear a mask in public or other personal protective equipment (PPE) as appropriate, especially when indicated at work or specific to at-risk occupations.
- Maintain physical distancing from others at work and in public.
- Limit contact with others as much possible and as practical.
- Maintain a supply of preparedness resources and supplies, including medications.
- Screening/testing vigilance is critical to data acquisition, risk mitigation and understanding COVID. Per the CDC, asymptomatic patients are tested at the discretion of the healthcare professional (HCP) and the facility recommendations.
- Be astute to social determinants of health and health inequities to ensure access to testing resources within all communities.
Infection Prevention Strategies for Staff
The core strategies communicated since the outbreak still hold value in keeping yourself and your patients safe:
- Wash your hands frequently with soap and water for at least 20 seconds. Hand sanitizer with 60% alcohol is the secondary choice when soap and water is not available.
- Cover your coughs and sneezes with the inside of your elbow.
- Keep your hands away from your face.
- Wear PPE and follow CDC guidelines when encountering known and suspected COVID patients.
- Implement safety precautions to reduce viral spread during delivery; instruct patients to call prior to arriving at the hospital so that safety precautions can be implemented.
Considerations within the OB Unit
Protecting and Educating Staff
All staff need to understand that COVID is highly contagious. Intrapartum safety with infection control practices is essential – including the use of PPE and N95 respirator masks – when caring for COVID-positive patients or those suspected of having COVID.
N95 masks offer greater protection than regular surgical face masks and are highly recommended for any aerosol-generating procedure. Eyeglasses do not count as PPE, so protective eyewear such as goggles or full-face shields should be worn. It is highly recommended that staff train and practice donning and doffing PPE, especially newer staff that may not be familiar with the procedure.
While PPE is crucial to risk mitigation, environmental sanitization and frequent diligent handwashing is known to be paramount in the optimization of decreasing transmission risk.
Testing and Caring for Patients
Areas with a high prevalence of COVID infection may want to consider universal testing for all asymptomatic pregnant patients at the time of admission to labor and delivery.
Suspected COVID patients are those that have had a recent high-risk contact occurrence or are symptomatic and have not been tested or have results pending. Some facilities choose universal testing of all patients. Suspected cases do not include those patients without a recent high-risk contact or those that remain asymptomatic.
Follow state, local and hospital policy guidelines.
Provide care for suspected COVID or confirmed COVID-positive patients in a single-person room with the door closed. Isolation rooms are reserved for those patients requiring aerosol-generating procedures.
Infants born to patients suspected of having COVID for whom results are not yet available (pending result or not tested) are not suspected of having COVID.
Infants born to those with known positive COVID status are considered to be of suspected COVID status. These infants should be isolated from other healthy infants, tested for COVID, and cared for following CDC guidelines and recommendations.
Visitors should be limited to only those essential to the mother’s well-being during the intrapartum stay; this is typically limited to one person during the entire intrapartum stay. Additional support members should be encouraged to call in to provide emotional support.
All visitors should have limited access only to the room they are visiting; they should not roam the hallways or other areas of the OB unit.
The option to breastfeed remains a decision to be made between the patient, her family, and the healthcare team. Mother-baby separation has not established improved outcomes and remains controversial. All patients should have risk/benefit education and be informed that breastfeeding is viewed as optimal infant nutrition.
One of the newest recommendations comes from The American Academy of Pediatrics (AAP) (July 2020); they support not separating infants from their COVID-positive mothers and that all family members should participate in safety precautions by wearing a mask and performing very careful hand hygiene when coming into contact with the newborn.
There are very rare instances when breastfeeding or human milk is not recommended for an infant. The benefits of skin-to-skin, mother-infant contact and breastfeeding remain abundant and well-documented within the literature.
A recent August release from The World Health Organization (WHO) reports that the benefits of breastfeeding a newborn substantially outweigh the potential risks of COVID and that all mothers – whether suspected or confirmed with COVID – should be encouraged to breastfeed their newborns while maintaining safety precautions.
It is believed to be unlikely that the virus is transmitted in breastmilk; the route of transmission to neonates is probably via respiratory droplets (hence the importance of the mother wearing a mask). Mothers should be informed that data is limited, research is ongoing, and it is not known whether COVID is transmissible via breastmilk. Recent research has shown viral fragments in breastmilk but no live virus.
Discuss with the patient whether to breastfeed or pump. If the mother is COVID-confirmed, she should take extreme precautions with breastfeeding, including scrupulous handwashing and mask-wearing during feeding. There is no evidence currently to support any benefit from precautions such as washing or wiping off the breast prior to breastfeeding or pumping. Mothers should follow the CDC guidelines for cleaning the breast pump and pump parts prior to and after pumping. This guidance may be updated as more research becomes available.
A recent study conducted from March 22nd to May 17th in three New York Hospitals revealed that no cases of viral transmission occurred among 120 babies born to 116 COVID-positive mothers, even when both shared a room and the mother was breastfeeding. This study led researchers to report that it is unlikely that a COVID-positive mother would pass the virus to her infant if proper precautions were taken – isolette placed 6 feet from the mother, mother handwashed before feeding and wore a mask for the duration of the feeding.
Newborn follow-up visits can be done in person; however, remote telemedicine lactation support and consultation post-discharge is an option that may be considered if an in-person visit is not deemed safe or appropriate. All lactation consultant providers should don PPE for COVID-positive patients and those suspected of having COVID.
HCPs should be notified of infants that are at high risk of exposure to COVID at home. While COVID in term infants has been mild or asymptomatic with complete recovery, there also exists the rarity of severe disease requiring mechanical ventilation. We have all heard about the 85 infants from Texas with COVID, some of whom were reported as incredibly ill. Symptomatology reported in infants includes cough, fever, respiratory difficulty, tachypnea, lethargy rhinorrhea, cough, and feeding intolerance with vomiting and diarrhea. Regardless of whether the infant exhibits signs and symptoms, testing is recommended for all infants whose mothers are COVID-positive or COVID-suspect.
Maternal Mental Health
COVID-associated stress, anxiety and depression are all behavioral health issues cited among the general population that are also applicable to the obstetric population. Pregnant and postpartum women should be considered at risk for these issues. Make it known to your patients that the pandemic has presented multiple concerning issues and that it is normal to feel anxious, depressed or stressed. Screening for postpartum depression, illicit substance abuse, and domestic violence remains crucial.
Supply your patient with resource materials and provide referrals for appropriate treatment and therapy. Encourage patients to talk to their healthcare team about their concerns and let them know where they can seek help. Free online resources to assist with maternal mental health are available through the CDC, the National Institute of Mental Health, and Mentalhealth.gov.
As always, it is critical to stay up to date by following the CDC and other professional organization websites – ACOG, AWHONN, AAP and ABM – in reporting recent research and consensus updates. ACOG updates are based on the CDC website and studies of pregnant women with confirmed COVID cases. The ACOG and CDC sites update frequently and provide pertinent information as it becomes available.
Keeping up to date with national and local statistics and policies is also highly recommended. You can follow your own state’s trends and track numbers at this Johns Hopkins website: https://coronavirus.jhu.edu/testing/tracker/overview.
We need to remember that much is still unknown about the coronavirus. Continue to educate yourself, your patients, and your peers with objective findings. Continue to provide fair and equitable care to all patients. Continue to report COVID cases and findings. Above all, continue to remain professional and stay safe.
ACOG. COVID Information Updates. https://www.acog.org/en/Topics/COVID-19
Berghella, V. Coronavirus disease 2019: Pregnancy Issues. Up-to-Date. August 2020. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-pregnancy-issues
CDC. Coronavirus Updates.
CDC. Coronavirus and Breastfeeding. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/covid-19-and-breastfeeding.html
Chen, H., Guo, J., Wang, C. et al. Clinical Characteristics of Vertical transmission potential of COVID 19 infection in 9 pregnant women. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30360-3/fulltext
Comeau, N. COVID-19 fears may widen gaps in early pregnancy care. 192(30), E870. 2020. https://www.cmaj.ca/content/192/30/E870
Ellington. S, Strid, P., Tong, VT. Characteristics of women of women of reproductive age with laboratory confirmed SARS-CoV-2 infection by pregnancy status in the US. https://www.cdc.gov/mmwr/volumes/69/wr/mm6925a1.htm
Jago, C Singh, S. & Moretti F. Coronavirus Disease 2019 (COVID-19) and Pregnancy: Combating isolation to improve Outcomes. Obstetrics and Gynecology. Volume 136, #1, July 2020.
Karimi, F., Razak, R. CNN reporting on 85 infants under the age of one test positive for coronavirus in Texas. https://www.cnn.com/2020/07/18/health/texas-infants-coronavirus-trnd/index.html
Kreis, N.-N., Ritter, A., Louwen, F. et al. A Message from the Human Placenta: Structural and Immunomodulatory Defense against SARS-CoV-2. Cells, 9, 1777. 2020. https://www.mdpi.com/2073-4409/9/8/1777
Molina, L. P., Chow, S-K, Nickel, A. et al. Prolonged Detection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RNA in an Obstetric Patient with Antibody Seroconversion. Obstetrics & Gynecology. July 21, 2020. https://journals.lww.com/greenjournal/Abstract/9000/Prolonged_Detection_of_Severe_Acute_Respiratory.97292.aspx
Niles, P. M., Asiodu, I. V., Crear-Perry, J., et al. Health Equity. Jul 2020, 330-333. https://www.liebertpub.com/doi/10.1089/heq.2020.0022#.XySGl9Kbkew.twitter
Onwuzurike, C., Meadows, A. & Nour, N. Examining Inequities Associated with Changes in Obstetric and Gynecologic Delivery During the Coronavirus Disease (COVID-19) Pandemic. Obstetrics and Gynecology. Volume 136, #1, July 2020.
Perlman, J, et al. Delivery room preparedness and early neonatal outcomes during COVID-19 pandemic in New York City. Pediatrics. 2020; 146(2):e20201567.
Peryer, M. CNN Reporting: COVID-19 and breastfeeding moms unlikely to pass virus to newborns with proper safety techniques in place.
Salvatore, C., Han, J. Acker, K. et al. Neonatal Management and Outcomes during the COVID 19 Pandemic. https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30235-2/fulltext
Vivant, A. et al. Transplacental transmission of Sars-CoV2 infection (peer review). Journal of Nature Communications. July 14, 2020. https://www.nature.com/articles/s41467-020-17436-6
Wyckoff, A. Ed. AAP News Release Update on COVID and breastfeeding: Rooming-in with precautions now ok in revised AAP newborn guidance. July 22, 2020. https://www.aappublications.org/news/2020/07/22/newbornguidance072220