Pregnant women who have known or suspected COVID-19 infection need to be evaluated quickly to determine the severity of their symptoms and if they have risk factors that put them at risk for severe disease. New data on the outcomes for pregnant women have shown that pregnancy is a risk factor for increased severe mortality and morbidity; for example, respiratory distress requiring intubation and admission to ICU, maternal death, and obstetric complications such as preterm birth and stillbirth (Jama Intern Med 2021).
Seven percent of pregnant women who underwent testing for COVID-19 were found to be positive, with 75%-85% asymptomatic and 90% stable enough to be treated outpatient. Thus, most women diagnosed with this infection can be treated without hospitalization, but all known or suspected infected patients must be closely monitored.
Pregnant women who present with exposure to an infected person and/or symptoms or signs of a COVID-19 infection – such as fever, cough, HA, sore throat, new loss of taste or smell, fatigue, myalgias, GI symptoms (diarrhea, nausea, vomiting), rhinorrhea, chills, difficulty breathing and/or SOB – should be tested for infection with the SARS-CoV-2. Test results for infection are not affected by a patient’s recent vaccination against this virus.
Antigen testing can be performed quickly, usually in 15 minutes; but it is not as sensitive as reverse transcription-PCR nucleic acid antigen (NAAT) testing, so the CDC recommends confirmatory testing with NAAT technology if symptoms or exposure warrant. Antigen tests can initially be negative, so re-testing can be helpful if symptoms persist or worsen. Antibody tests that are positive for SARS-CoV-2 indicate only that the patient has been exposed to the virus; they are not necessarily accurate to diagnose a current infection.
Pregnant women who are complaining of more concerning symptoms of COVID-19 such as SOB with difficulty completing a sentence or walking across the room, new pain or pressure in the chest with coughing, dehydration from vomiting or unable to keep liquids down, and confusion are considered by ACOG’s COVID guidance algorithm to be at an elevated risk for severe infection. They should be evaluated as soon as possible at the hospital (ED or L&D as warranted by gestational age).
If the patient has comorbidities known to increase the risk of severe COVID-19 infection, she is considered to be a moderate risk and should be evaluated as soon as possible in an ambulatory setting where testing such as pulse oximetry, CXR, or ABG can be obtained. Concerning comorbidities include: HTN; DM; lung conditions such as asthma; heart, liver, lung or kidney disease; and an immunosuppressed state due to HIV, medications, or medical condition. Race can be a factor, which increases risk status with Black, Hispanic or American-Indian groups experiencing higher rates of hospitalization and death from an infection.
Additional situations that can increase a pregnant woman’s risk for severe COVID-19 symptoms include a social environment where she has limited resources for remote at-home care and monitoring. Other patients with concerning situations are those with no internet access, who live alone or are undomiciled, and who have limited or no transportation for an in-person evaluation if symptoms worsen.
Patients at risk for obstetrical complications, poor outcomes, stillbirth and premature labor may need to be evaluated in person. Offices and ambulatory testing units must ensure that all precautions are followed to protect providers, office staff and other patients from infection; isolated exam and testing rooms or ambulatory sites should be set up to accommodate patients with known or suspected COVID-19 infections. If providers’ offices cannot safely treat these patients in person, an established site can be identified and made available for them.
Patients who are stable and not in an increased risk situation can continue to be monitored at home. If telemedicine video conferencing communication is preferred to phone calls, secure platforms such as Doxyme can be used.
What is currently recommended for outpatient treatment of pregnant patients with documented or suspected COVID-19 infection? There are currently no known preventive treatments for post-SARS-CoV-2 exposure or for known infection. Trials are underway now, but no pregnant women are enrolled, so data on safety in pregnancy may never be known. For now, we have safe symptomatic relief and preventive care treatments.
The provision of safe, comprehensive prenatal care for women with known or suspected COVID-19 infections requires protocols for remote patient communication and a system that can provide timely responses to patient concerns about exposure or suspicious symptoms, for example. Providers must have resources for rapid testing and reporting for their patients. OB practices must identify a site for patient evaluation that is safe for office staff and patients. Hopefully, more information will be forthcoming about the optimal treatments for pregnant women with a SARS-CoV-2 infection.