COVID-19 in Pregnant Women and Lactating Mothers
Author: Dr. Guneet J Mann, MD
Having a baby is exciting and exhausting work. Hence the term, “Labor”. But these are the “CORONA TIMES” and the medical care protocols are evolving every day to fight the pandemic. New information about the virus and its effect in different health scenarios also keeps pouring in. One subset of the population that demands special attention is the pregnant woman and effect of the coronavirus on different aspects of pregnancy and lactation.
Susceptibility of Pregnant Women to COVID-19
Currently there is limited information from published scientific reports about the susceptibility of pregnant woman to COVID-19 and the severity of infection. The available data is limited to small case series. The immunologic and physiologic changes that normally occur in a pregnancy, make a pregnant woman more susceptible to viral respiratory infections such as influenza virus, hence they could be more susceptible to COVID-19 as well. It is probable that pregnant woman might be at a greater risk for severe illness compared to the general population, as is observed with other related Coronavirus infections including SARS-CoV (Severe Acute Respiratory Syndrome Coronavirus) and MERS-CoV (Middle East Respiratory Syndrome Corona Virus).
The currently published data on COVID-19 infection in pregnancy includes two case series, totaling 18 women only one of whom suffered severe respiratory morbidity requiring ICU admission and mechanical ventilation (this is lower than the general population risk). While these data are reassuring that pregnant women didn’t have severe outcomes, they have to be interpreted cautiously, given the small numbers.
COVID-19 and the risk of miscarriage or congenital anomalies
Currently, there is inadequate data on the risk of miscarriage or congenital anomalies due to COVID-19. Chen et al 1 found no evidence of COVID-19 in the amniotic fluid or cord blood of six infants of infected women. This lack of vertical transmission of virus is consistent with what is seen with other common respiratory viral illnesses in pregnancy, such as influenza.
Antenatal follow up in COVID-19 pregnancies
Since very little is known about the natural course of the disease in pregnant patients, a detailed mid-trimester anatomy ultrasound examination may be considered following first trimester maternal infection. For those experiencing illness later in pregnancy, it is reasonable to consider sonographic assessment of fetal growth in the third trimester.
Preterm delivery in COVID-19 patients
Though preterm delivery has been reported among infants born to COVID-19 mothers, it is not clear whether these outcomes were related to maternal infection or they were iatrogenic. Infants born to mothers with other Coronavirus infections, including SARS-CoV and MERS-CoV, have been preterm and / or small for gestational age.
Delivery in COVID-19 patients
For women infected early in pregnancy, who recover, no alteration to the usual timing of delivery is necessary. For those who are infected in the third trimester and have recovered, attempt to postpone delivery (if no other medical conditions arise) either until a negative testing result is obtained or quarantine status is lifted. This is an attempt to avoid transmission of COVID-19 to the neonate.
In general COVID-19 infection in itself is not an indication for delivery. The mode of delivery should be according to the usual obstetric practices.
Rooming-In of newborn with COVID-19 mother
The bond between the mother and the new born infant begins as they get to know each other better. The practice of keeping the new born in the mother’s hospital room, preferably by the side of her bed, instead of in a nursery is called Rooming-In. This is followed in most hospitals and nursing homes across the globe.
At this time, the CDC recommends that hospitals and nursing homes should consider temporarily separating (e.g. separate rooms) a woman with confirmed COVID-19 or who is a PUI (Person under Investigation) for COVID-19 from her infant. This is to be done until the woman’s transmission based precaution are discontinued. This means Rooming-In is could be delayed for a period which could extend from 72 hours to 7 days and in some cases up to 14 days. As per the CDC, the health risks and benefits of separation should be discussed with the mother and she should be involved in decision making. This practice is recommended based on the fact that infection is essentially transmitted to the neonate after birth through infectious respiratory droplets.
Breastfeeding by COVID-19 lactating mothers
Chen et al 1 found no evidence of Coronavirus in the breast milk of nine infected women. In fact, breast feeding is to be encouraged since it is a potential source of antibodies for the protection of the infant.
The CDC recommends that during separation of the mother from the neonate, breast feeding should be started and maintained by using breast pumps. The expressed milk should be fed to the new born by a healthy caregiver. A dedicated breast pump should be used before expressing breast milk, women should wash their hands with soap and water for 20 seconds. After pumping, all parts of the pump that come in contact with the breast milk should be thoroughly washed and the entire pump should be appropriately disinfected as per the manufacturer’s instruction.
For women who are not separated from their babies and who want to feed their newborns, wearing a facemask and practicing hand hygiene before each feed is essential.
High Risk COVID-19 Pregnancies
Pregnant woman who have severe chronic medical disorders such as Heart, lung or kidney disease should follow the CDC precautions and guidelines. These include general practices like stocking up supplies, hand hygiene, social distancing and limiting contact with sick people. They should avoid crowds and stay at home as much as possible.
As COVID-19 is a very recent disease, a lot needs to be discovered about its various aspects. There are ongoing investigations on SARS-COV-2 by the scientific community and information on this is continually being updated. It is strongly advised that readers should keep themselves abreast with the latest news.
The above advisory is true as per the facts known on 27th March 2020.
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