Dr. Pallavi Sharma, Dr. Anil Mehta
The COVID 19 pandemic, which requires no introduction by now, has hit the whole humanity in its face and challenged our sense of well-being and security at different levels. Apparently, there is no physical boundary that this virus cannot cross and has penetrated globally, affecting around 200 countries. Its origin dates back to Dec 2019 when it was first reported from the Hubei province of China. So far, this has taken thousands of lives world over and has crippled many economies.
The risk of contracting the illness is more in the elderly, immuno- compromised individuals and those with underlying medical disorders. Owing to the physiological immuno-compromise of pregnancy, expectant mothers form a vulnerable group requiring extra attention and care. The obstetric bodies all over the world have been studying the trend of this infection though it is believed that pregnant women hold the same status of getting infected as their non-pregnant counterparts.
The influence of COVID 19 on pregnancy is under research. There is no placental transmission of the virus and no proven teratogenicity. If a woman gets infected in the first trimester there is no need for termination of pregnancy and there have been no spontaneous pregnancy losses either. Given the current evidence, it is considered unlikely that it has effect on fetal development. The transmission from mother to child has not been reported in a study of 38 women from China. The study claimed that virus was not identified in the amniotic fluid, placenta, breast milk or in the nasal secretions of neonates. On the contrary, a new born in London recently tested positive for the virus after birth. According to the Indian Council of Medical Research (ICMR), there is a possibility of transmission of coronavirus from a pregnant mother to the neonate. However, the proportion of pregnancies affected and the significance to the newborn is yet to be determined.
Pregnant women should take good care of themselves during this time. A healthy and balanced diet is essential to develop good immunity. The usual supplements like folic acid, iron and calcium should be continued along with vitamin C and zinc (immune boosters). Good sleep and hydration along with gentle breathing exercises are advisable. Hand washing using soap and water for a minimum of 20 seconds and use of alcohol based hand rub to sanitize hands after touching any surface, before and after meals should be practiced. Mouth should be covered with a flexed elbow/tissue or cloth while coughing or sneezing with immediate disposal of the tissue. Public transport and coming in contact with people having flu like symptoms should be avoided. It is advised not to self-medicate in case of any problem. Antibiotics do not help in this infection and vaccines are still under trial. Several agents like Hydroxychloroquine are being evaluated for treatment of COVID-19, though there are no high-quality studies documenting the role of Hydroxychloroquine or Remdesivir in the treatment of pregnant women.
During a scheduled appointment women are advised to note their concerns for an elaborate discussion. Four visits at 12, 20, 28 and 36 weeks are recommended for low risk cases. These cases can also be managed through tele-conferencing and video conferencing. This contributes in reducing the number of in-person visits, timing of visits, minimizing maternal contact with others, reducing the inflow of relatives coming to the hospital with the patients. It is a good idea to discuss the need of a particular investigation depending on the period of pregnancy and go handy with the report to avoid frequent visits (Ultrasounds for Gestational age, fetal anomaly, fetal growth, and placental attachment/blood tests). In presence of any underlying high risk factor or acute problem this protocol changes and women are advised to contact the nearest health care facility immediately. For those with increased blood pressure, frequent charting of blood pressure is advised. Medicines should be arranged a few days before they are about to finish. The routine immunization schedule of pregnancy remains unchanged.
For women who have had symptoms, appointments can be deferred until 7 days after the start of symptoms, unless the problem (aside from persistent cough) becomes severe. Fetal Kick count should be maintained. If needed to visit health centre, public transport should be avoided. Arrange self-transport or call 108, informing the ambulance staff about the status. For women who are self-quarantined because someone in their household has possible symptoms of COVID-19, appointments should be deferred for 14 days even if a woman has previously tested negative for COVID-19. If she presents with symptoms again, COVID-19 should be suspected. Referral to antenatal ultrasound services for fetal growth surveillance is recommended after 14 days following the resolution of acute illness.
The need for delivery is individualized and depends on feto-maternal parameters. COVID 19 is not an indication to induce labor if not otherwise indicated. It has not been proven that cesarean birth is better than a vaginal delivery. In symptomatic patients there is a need to individualize the need for continuation versus termination of pregnancy. The concept of birth companion is not advisable in the current situation.
Mothers who intend to breastfeed during temporary separation should be encouraged to express their breast milk to establish and maintain milk supply. If possible, a dedicated breast pump should be provided. Prior to expressing breast milk, mothers should practice hand hygiene. After each pumping session, all parts that come into contact with breast milk should be thoroughly washed and the entire pump should be appropriately disinfected as per the manufacturer’s instructions. This expressed breast milk should be fed to the new-born by a healthy caregiver. If a mother and new-born do room-in and the mother wishes to feed at the breast, she should put on a facemask and practice hand hygiene before each feeding.
To provide optimum care to the pregnant woman guidelines have been released on 1st April 2020 by of the Federation of Obstetric and Gynecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP). These guidelines are about the prevention of transmission, diagnosis of infection and providing clinical care during labor, resuscitation and postnatal period. Pregnancy registries are being done worldwide to collect data about how COVID 19 affects pregnancies and newborns.
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