In response to the World Health Organization (WHO) statements and international concerns
regarding the novel coronavirus infection (COVID‐19) outbreak, the International Society
of Ultrasound in Obstetrics and Gynecology (ISUOG) is issuing the following guidance
for management during pregnancy and puerperium.
With the current uncertainty regarding many aspects of the clinical course of COVID‐19
infection in pregnancy, potentially valuable information is likely to be obtained
by obstetricians and ultrasound practitioners that may help in counseling pregnant
women and further improve our understanding of the pathophysiology of COVID‐19 infection
in pregnancy. This statement is not intended to replace previously published interim
guidance on evaluation and management of COVID‐19‐exposed pregnant women. It should,
therefore, be considered in conjunction with other relevant advice from organizations
such
as:
WHO: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
Centers for Disease Control and Prevention (CDC): https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnancy-faq.html
Pan American Health Organization (PAHO): http://www.paho.org
European Centre for Disease Prevention and Control (ECDC): https://www.ecdc.europa.eu
Public Health England: https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public
National Health Commission of the People's Republic of China: http://www.nhc.gov.cn
Perinatal Medicine Branch of Chinese Medical Association: https://mp.weixin.qq.com/s/11hbxlPh317es1XtfWG2qg
Indicazioni ad interim della Societa Italiana di Neonatologia (SIN): https://www.policlinico.mi.it/uploads/fom/attachments/pagine/pagine_m/79/files/allegati/539/allattamento_e_infezione_da_sars-cov-2_indicazioni_ad_interim_della_societ___italiana_di_neonatologia_sin__2_.pdf
Santé Publique France https://www.santepubliquefrance.fr/
Sociedad Española de Ginecología y Obstetricia S.E.G.O.: https://mcusercontent.com/fbf1db3cf76a76d43c634a0e7/files/1abd1fa8-1a6f-409d-b622-c50e2b29eca9/RECOMENDACIONES_PARA_LA_PREVENCIO_N_DE_LA_INFECCIO_N_Y_EL_CONTROL_DE_LA_ENFERMEDAD_POR_CORONAVIRUS_2019_COVID_19_EN_LA_PACIENTE_OBSTE_TRICA.pdf
Royal College of Obstetricians and Gynaecologists (RCOG): https://www.rcog.org.uk/globalassets/documents/guidelines/coronavirus-covid-19-infection-in-pregnancy-v3-20-03-18.pdf
BACKGROUND
The novel coronavirus infection (COVID‐19), also termed SARS‐CoV‐2, is a global public
health emergency. Since the first case of COVID‐19 pneumonia was reported in Wuhan,
Hubei Province, China, in December 2019, the infection has spread rapidly to the rest
of China and beyond1, 2, 3.
Coronaviruses are enveloped, non‐segmented, positive‐sense ribonucleic acid (RNA)
viruses belonging to the family Coronaviridae, order Nidovirales4. The epidemics of
the two β‐coronaviruses, severe acute respiratory syndrome coronavirus (SARS‐CoV)
and Middle East respiratory syndrome coronavirus (MERS‐CoV), have caused more than
10 000 cumulative cases in the past two decades, with mortality rates of 10% for SARS‐CoV
and 37% for MERS‐CoV5, 6, 7, 8, 9. COVID‐19 belongs to the same β‐coronavirus subgroup
and it has genome similarity of about 80% and 50% with SARS‐CoV and MERS‐CoV, respectively10.
COVID‐19 is spread by respiratory droplets and direct contact (when bodily fluids
touch another person's eyes, nose or mouth, or an open cut, wound or abrasion). The
Report of the World Health Organization (WHO)‐China Joint Mission on Coronavirus Disease
2019 (COVID‐19)11 estimated a high R
0
(reproduction number) of 2–2.5. The latest report from WHO12, on March 3rd, estimated
the global mortality rate of COVID‐19 infection to be 3.4%.
Huang et al.1 first reported on a cohort of 41 patients with laboratory‐confirmed
COVID‐19 pneumonia. They described the epidemiological, clinical, laboratory and radiological
characteristics, as well as treatment and clinical outcome of the patients. Subsequent
studies with larger sample sizes have shown similar findings13, 14. The most common
symptoms reported are fever (43.8% of cases on admission and 88.7% during hospitalization)
and cough (67.8%)15. Diarrhea is uncommon (3.8%). On admission, ground‐glass opacity
is the most common radiologic finding on computed tomography (CT) of the chest (56.4%).
No radiographic or CT abnormality was found in 157 of 877 (17.9%) patients with non‐severe
disease and in five of 173 (2.9%) patients with severe disease. Lymphocytopenia was
reported to be present in 83.2% of patients on admission15.
Pregnancy is a physiological state that predisposes women to respiratory complications
of viral infection. Due to the physiological changes in their immune and cardiopulmonary
systems, pregnant women are more likely to develop severe illness after infection
with respiratory viruses. In 2009, pregnant women accounted for 1% of patients infected
with influenza A subtype H1N1 virus, but they accounted for 5% of all H1N1‐related
deaths16. In addition, SARS‐CoV and MERS‐CoV are both known to be responsible for
severe complications during pregnancy, including the need for endotracheal intubation,
admission to an intensive care unit (ICU), renal failure and death9, 17. The case
fatality rate of SARS‐CoV infection among pregnant women is up to 25%9. Currently,
however, there is no evidence that pregnant women are more susceptible to COVID‐19
infection or that those with COVID‐19 infection are more prone to developing severe
pneumonia.
Over and above the impact of COVID‐19 infection on a pregnant woman, there are concerns
relating to the potential effect on fetal and neonatal outcome; therefore, pregnant
women require special attention in relation to prevention, diagnosis and management.
Based on the limited information available as yet and our knowledge of other similar
viral pulmonary infections, the following expert opinions are offered to guide clinical
management.
DIAGNOSIS OF INFECTION AND CLINICAL CLASSIFICATION
Case definitions are those included in the WHO's interim guidance, ‘Global surveillance
for COVID‐19 disease caused by human infection with the 2019 novel coronavirus’18.
Suspected case
A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory
disease (e.g. cough, shortness of breath)) AND with no other etiology that fully explains
the clinical presentation AND a history of travel to or residence in a country/area
or territory reporting local transmission of COVID‐19 infection during the 14 days
prior to symptom onset; OR
A patient with any acute respiratory illness AND who has been in contact (see definition
of contact below) with a confirmed or probable case of COVID‐19 infection in the 14 days
prior to onset of symptoms; OR
A patient with severe acute respiratory infection (fever and at least one sign/symptom
of respiratory disease (e.g. cough, shortness breath)) AND who requires hospitalization
AND who has no other etiology that fully explains the clinical presentation.
Probable case
A suspected case for which laboratory testing for COVID‐19 is inconclusive.
Confirmed case
A person with laboratory confirmation of COVID‐19 infection, irrespective of clinical
signs and symptoms.
It is plausible that a proportion of transmissions occurs from cases with mild symptoms
that do not provoke healthcare‐seeking behavior. Under these circumstances, in areas
in which local transmission occurs, an increasing number of cases without a defined
chain of transmission is observed19 and a lower threshold for suspicion in patients
with severe acute respiratory infection may be recommended by health authorities.
Any suspected case should be tested for COVID‐19 infection using available molecular
tests, such as quantitative reverse transcription polymerase chain reaction (qRT‐PCR).
Lower‐respiratory‐tract specimens likely have a higher diagnostic value compared with
upper‐respiratory‐tract specimens for detecting COVID‐19 infection. The WHO recommends
that, if possible, lower‐respiratory‐tract specimens, such as sputum, endotracheal
aspirate or bronchoalveolar lavage, be collected for COVID‐19 testing. If patients
do not have signs or symptoms of lower‐respiratory‐tract disease or specimen collection
for lower‐respiratory‐tract disease is clinically indicated but collection is not
possible, upper‐respiratory‐tract specimens of combined nasopharyngeal and oropharyngeal
swabs should be collected. If initial testing is negative in a patient who is strongly
suspected of having COVID‐19 infection, the patient should be resampled, with a sampling
time interval of at least 1 day and specimens collected from multiple respiratory‐tract
sites (nose, sputum, endotracheal aspirate). Additional specimens, such as blood,
urine and stool, may be collected to monitor the presence of virus and the shedding
of virus from different body compartments. When qRT‐PCR analysis is negative for two
consecutive tests, COVID‐19 infection can be ruled
out.
A contact is defined as a person involved in any of the following:
Providing direct care for COVID‐19 patients without using proper personal protective
equipment (PPE)
Being in the same close environment as a COVID‐19 patient (including sharing workplace,
classroom or household, or attending the same gathering)
Traveling in close proximity (within 1–2 meters) to a COVID‐19 patient in any kind
of conveyance
The WHO has provided guidance on the rational use of PPE for COVID‐19. When conducting
aerosol‐generating procedures (e.g. tracheal intubation, non‐invasive ventilation,
cardiopulmonary resuscitation, manual ventilation before intubation), healthcare workers
are advised to use respirators (e.g. N95, FFP2 or equivalent standard) with their
PPE20, 21. CDC additionally considers procedures that are likely to induce coughing
(e.g. sputum induction, collection of nasopharyngeal swabs and suctioning) as aerosol‐generating
procedures and CDC guidance includes the option of using a powered air‐purifying respirator
(PAPR).
CHEST RADIOGRAPHY DURING PREGNANCY
Chest imaging, especially CT scan, is essential for evaluation of the clinical condition
of a pregnant woman with COVID‐19 infection22, 23, 24. Fetal growth restriction (FGR),
microcephaly and intellectual disability are the most common adverse effects from
high‐dose (> 610 mGy) radiation exposure25, 26, 27. According to data from the American
College of Radiology and American College of Obstetricians and Gynecologists, when
a pregnant woman undergoes a single chest X‐ray examination, the radiation dose to
the fetus is 0.0005–0.01 mGy, which is negligible, while the radiation dose to the
fetus is 0.01–0.66 mGy from a single chest CT or CT pulmonary angiogram28, 29, 30.
Chest CT scanning has high sensitivity for diagnosis of COVID‐1924. In a pregnant
woman with suspected COVID‐19 infection, a chest CT scan may be considered as a primary
tool for the detection of COVID‐19 in epidemic areas24. Informed consent should be
acquired (shared decision‐making) and a radiation shield be applied over the gravid
uterus.
TREATMENT DURING PREGNANCY
Place of care
Suspected, probable and confirmed cases of COVID‐19 infection should be managed initially
by designated tertiary hospitals with effective isolation facilities and protection
equipment. Suspected/probable cases should be treated in isolation and confirmed cases
should be managed in a negative‐pressure isolation room. A confirmed case that is
critically ill should be admitted to a negative‐pressure isolation room in an ICU31.
Designated hospitals should set up a dedicated negative‐pressure operating room and
a neonatal isolation ward. All attending medical staff should don PPE (respirator,
goggle, face protective shield, surgical gown and gloves) when providing care for
confirmed cases of COVID‐19 infection32.
However, in areas with widespread local transmission of the disease, health services
may be unable to provide such levels of care to all suspected, probable or confirmed
cases. Pregnant women with a mild clinical presentation may not initially require
hospital admission and home confinement can be considered, provided that this is possible
logistically and that monitoring of the woman's condition can be ensured33. If negative‐pressure
isolation rooms are not available, patients should be isolated in single rooms, or
grouped together once COVID‐19 infection has been confirmed.
For transfer of confirmed cases, the attending medical team should don PPE and keep
themselves and their patient a minimum distance of 1–2 meters from any individuals
without
PPE.
Suspected/probable cases
General treatment: maintain fluid and electrolyte balance; symptomatic treatment,
such as antipyrexic, antidiarrheal medicines.
(1) Surveillance: close and vigilant monitoring of vital signs and oxygen saturation
level to minimize maternal hypoxia; conduct arterial blood‐gas analysis; repeat chest
imaging (when indicated); regular evaluation of complete blood count, renal‐ and liver‐function
testing and coagulation testing. (2) Fetal monitoring: undertake cardiotocography
(CTG) for fetal heart rate (FHR) monitoring when pregnancy is ≥ 26 or ≥ 28 weeks of
gestation (depending on local practice), and ultrasound assessment of fetal growth
and amniotic fluid volume with umbilical artery Doppler if necessary. Note that monitoring
devices and ultrasound equipment should be disinfected adequately before further use.
(3) The pregnancy should be managed according to the clinical and ultrasound findings,
regardless of the timing of infection during pregnancy. All visits for obstetric emergencies
should be offered in agreement with current local guidelines. All routine follow‐up
appointments should be postponed by 14 days or until positive test results (or two
consecutive negative test results) are available.
Confirmed cases
Non‐severe disease. (1) The approach to maintaining fluid and electrolyte balance,
symptomatic treatment and surveillance is the same as for suspected/probable cases.
(2) Currently there is no proven antiviral treatment for COVID‐19 patients, although
antiretroviral drugs are being trialed therapeutically on patients with severe symptoms34,
35. If antiviral treatment is to be considered, this should be done following careful
discussion with virologists; pregnant patients should be counseled thoroughly on the
potential adverse effects of antiviral treatment for the patient herself as well as
on the risk of FGR. (3) Monitoring for bacterial infection (blood culture, mid‐stream
or catheterized‐specimen urine microscopy and culture) should be done, with timely
use of appropriate antibiotics when there is evidence of secondary bacterial infection.
When there is no clear evidence of secondary bacterial infection, empirical or inappropriate
use of antibiotics should be avoided. (4) Fetal monitoring: undertake CTG for FHR
monitoring when pregnancy is ≥ 26–28 weeks of gestation, and ultrasound assessment
of fetal growth and amniotic fluid volume with umbilical artery Doppler if necessary.
Severe and critical disease. (1) The degree of severity of COVID‐19 pneumonia is defined
by the Infectious Diseases Society of America/American Thoracic Society guidelines
for community‐acquired pneumonia (Appendix 1)36. (2) Severe pneumonia is associated
with a high maternal and perinatal mortality rate, therefore, aggressive treatment
is required, including supporting measures with hydration, oxygen therapy and chest
physiotherapy. The case should be managed in a negative‐pressure isolation room in
the ICU, preferably with the woman in a left lateral position, with the support of
a multidisciplinary team (obstetricians, maternal–fetal‐medicine subspecialists, intensivists,
obstetric anesthetists, midwives, virologists, microbiologists, neonatologists, infectious‐disease
specialists)37. (3) Antibacterial treatment: appropriate antibiotic treatment in combination
with antiviral treatment should be used promptly when there is suspected or confirmed
secondary bacterial infection, following discussion with microbiologists. (4) Blood‐pressure
monitoring and fluid‐balance management: in patients without septic shock, conservative
fluid management measures should be undertaken38; in patients with septic shock, fluid
resuscitation and inotropes are required to maintain an average arterial pressure
≥ 60 mmHg (1 mmHg = 0.133 kPa) and a lactate level < 2 mmol/L39. (5) Oxygen therapy:
supplemental oxygen should be used to maintain oxygen saturation ≥ 95%40, 41; oxygen
should be given promptly to patients with hypoxemia and/or shock42, and method of
ventilation should be according to the patient's condition and following guidance
from the intensivists and obstetric anesthetists. (6) Fetal monitoring: if appropriate,
CTG for FHR monitoring should be undertaken when pregnancy is ≥ 26–28 weeks of gestation,
and ultrasound assessment of fetal growth and amniotic fluid volume with umbilical
artery Doppler should be performed, if necessary, once the patient is stabilized.
(7) Medically indicated preterm delivery should be considered by the multidisciplinary
team on a case‐by‐case basis.
MANAGEMENT DURING PREGNANCY
Currently, there are limited data on the impact on the fetus of maternal COVID‐19
infection. It has been reported that viral pneumonia in pregnant women is associated
with an increased risk of preterm birth, FGR and perinatal mortality43. Based on nationwide
population‐based data, it was demonstrated that pregnant women with other viral pneumonias
(n = 1462) had an increased risk of preterm birth, FGR and having a newborn with low
birth weight and Apgar score < 7 at 5 min, compared with those without pneumonia (n = 7310)44.
In 2004, a case series of 12 pregnant women with SARS‐CoV in Hong Kong, China, reported
three maternal deaths, that four of seven patients who presented in the first trimester
had spontaneous miscarriage, four of five patients who presented after 24 weeks had
preterm birth and two mothers recovered without delivery but their ongoing pregnancies
were complicated by FGR9. Pregnant women with suspected/probable COVID‐19 infection,
or those with confirmed infection who are asymptomatic or recovering from mild illness,
should be monitored with 2–4‐weekly ultrasound assessment of fetal growth and amniotic
fluid volume, with umbilical artery Doppler if necessary45. At present, it is uncertain
whether there is a risk of vertical mother‐to‐baby transmission. In a study by Chen
et al.46, of nine pregnant women with COVID‐19 in the third trimester, amniotic fluid,
cord blood and neonatal throat‐swab samples collected from six patients tested negative
for COVID‐19, suggesting there was no evidence of intrauterine infection caused by
vertical transmission in women who developed COVID‐19 pneumonia in late pregnancy.
However, there are currently no data on perinatal outcome when the infection is acquired
in the first and early second trimester of pregnancy, and these pregnancies should
be monitored carefully after recovery.
ULTRASOUND EQUIPMENT
Following ultrasound examination, ensure surfaces of transducers are cleaned and disinfected
according to manufacturer specifications, taking note of the recommended ‘wet time’
for wiping transducers and other surfaces with disinfection agents47. Consider using
protective covers for probes and cables, especially when there are infected skin lesions
or when a transvaginal scan is necessary. In the case of high infectivity, a ‘deep
clean’ of the equipment is necessary. A bedside scan is preferred; if the patient
needs to be scanned in the clinic, this should be done at the end of the list, as
the room and equipment will subsequently require a deep clean. Reprocessing of the
probes should be documented for traceability47.
MANAGEMENT DURING CHILDBIRTH
COVID‐19 infection itself is not an indication for delivery, unless there is a need
to improve maternal oxygenation. For suspected, probable and confirmed cases of COVID‐19
infection, delivery should be conducted in a negative‐pressure isolation room. The
timing and mode of delivery should be individualized, dependent mainly on the clinical
status of the patient, gestational age and fetal condition48. In the event that an
infected woman has spontaneous onset of labor with optimal progress, she can be allowed
to deliver vaginally. Shortening the second stage by operative vaginal delivery can
be considered, as active pushing while wearing a surgical mask may be difficult for
the woman to achieve49. With respect to a pregnant woman without a diagnosis of COVID‐19
infection, but who might be a silent carrier of the virus, we urge caution regarding
the practice of active pushing while wearing a surgical mask, as it is unclear if
there is an increased risk of exposure to any healthcare professional attending the
delivery without PPE, because forceful exhalation may significantly reduce the effectiveness
of a mask in preventing the spread of the virus by respiratory droplets49. Induction
of labor can be considered when the cervix is favorable, but there should be a low
threshold to expedite the delivery when there is fetal distress, poor progress in
labor and/or deterioration in maternal condition. Septic shock, acute organ failure
or fetal distress should prompt emergency Cesarean delivery (or termination, if legal,
before fetal viability)45. For the protection of the medical team, water birth should
be avoided. Both regional anesthesia and general anesthesia can be considered, depending
on the clinical condition of the patient and after consultation with the obstetric
anesthetist.
For preterm cases requiring delivery, we urge caution regarding the use of antenatal
steroids (dexamethasone or betamethasone) for fetal lung maturation in a critically
ill patient, because this can potentially worsen the clinical condition50 and the
administration of antenatal steroids would delay the delivery that is necessary for
management of the patient. The use of antenatal steroids should be considered in discussion
with infectious‐disease specialists, maternal–fetal‐medicine subspecialists and neonatologists37,
51. In the case of an infected woman presenting with spontaneous preterm labor, tocolysis
should not be used in an attempt to delay delivery in order to administer antenatal
steroids.
Miscarried embryos/fetuses and placentae of COVID‐19‐infected pregnant women should
be treated as infectious tissues and they should be disposed of appropriately; if
possible, testing of these tissues for COVID‐19 by qRT‐PCR should be undertaken.
Regarding neonatal management of suspected, probable and confirmed cases of maternal
COVID‐19 infection, the umbilical cord should be clamped promptly and the neonate
should be transferred to the resuscitation area for assessment by the attending pediatric
team. There is insufficient evidence regarding whether delayed cord clamping increases
the risk of infection to the newborn via direct contact51. In units in which delayed
cord clamping is recommended, clinicians should consider carefully whether this practice
should be continued. There is currently insufficient evidence regarding the safety
of breastfeeding and the need for mother–baby separation46, 52. If the mother is severely
or critically ill, separation appears to be the best option, with attempts to express
breastmilk in order to maintain milk production. Precautions should be taken when
cleaning the breast pumps. If the patient is asymptomatic or mildly affected, breastfeeding
and colocation (also called rooming‐in) can be considered by the mother in coordination
with healthcare providers, or may be necessary if facility limitations prevent mother–baby
separation. Since the main concern is that the virus may be transmitted by respiratory
droplets rather than breastmilk, breastfeeding mothers should ensure to wash their
hands and wear a three‐ply surgical mask before touching the baby. In case of rooming‐in,
the baby's cot should be kept at least 2 meters from the mother's bed, and a physical
barrier such as a curtain may be used53, 54.
The need to separate mothers with COVID‐19 infection from their newborns, with the
consequence that they are unable to breastfeed directly, may impede early bonding
as well as establishment of lactation55. These factors will inevitably cause additional
stress for mothers in the postpartum period. As well as caring for their physical
wellbeing, medical teams should consider the mental wellbeing of these mothers, showing
appropriate concern and providing support when needed55.
PERINATAL EFFECT OF COVID‐19 INFECTION
Fever is common in COVID‐19‐infected patients. Previous data have demonstrated that
maternal fever in early pregnancy can cause congenital structural abnormalities involving
the neural tube, heart, kidney and other organs56, 57, 58, 59. However, a recent study60,
including 80 321 pregnant women, reported that the rate of fever in early pregnancy
was 10%, while the incidence of fetal malformation in this group was 3.7%. Among the
77 344 viable pregnancies with data collected at 16–29 weeks of gestation, in the
8321 pregnant women with a reported temperature > 38°C lasting 1–4 days in early pregnancy,
compared to those without a fever in early pregnancy, the overall risk of fetal malformation
was not increased (odds ratio = 0.99 (95% CI, 0.88–1.12))60. Previous studies have
reported no evidence of congenital infection with SARS‐CoV61, and currently there
are no data on the risk of congenital malformation when COVID‐19 infection is acquired
during the first or early second trimester of pregnancy. Nonetheless, a detailed morphology
scan at 18–24 weeks of gestation is indicated for pregnant women with suspected, probable
or confirmed COVID‐19 infection.
GENERAL PRECAUTIONS
Currently, there are no effective drugs or vaccines to prevent COVID‐19. Therefore,
personal protection should be considered in order to minimize the risk of contracting
the virus62.
Patients and healthcare providers
Maintain good personal hygiene: consciously avoid close contact with others during
the COVID‐19 epidemic period, reduce participation in any gathering in which a distance
of at least 1 meter between individuals cannot be maintained, pay attention to hand
washing and use hand sanitizer (with 70% alcohol concentration63) frequently.
Some national health authorities and some hospital systems recommend wearing a three‐ply
surgical mask when visiting a hospital or other high‐risk area.
Seek medical assistance promptly for timely diagnosis and treatment when experiencing
symptoms such as fever and cough.
Healthcare providers
d
Consider providing educational information (brochures, posters) in waiting areas.
e
Set up triage plans for screening. In units in which triage areas have been set up,
staff should have appropriate protective equipment and be strictly compliant with
hand hygiene.
f
All pregnant patients who present to the hospital and for outpatient visits should
be assessed and screened for symptoms and risk factors based on travel history, occupation,
significant contact and cluster (TOCC) (Appendix 2).
g
Pregnant patients with known TOCC risk factors and those with mild or asymptomatic
COVID‐19 infection should delay antenatal visit and routine ultrasound assessment
by 14 days.
h
Consider reducing the number of visitors to the department.
i
In units in which routine group‐B streptococcus (GBS) screening is practiced, acquisition
of vaginal and/or anal swabs should be delayed by 14 days in pregnant women with TOCC
risk factors or should be performed only after a suspected/probable case tests negative
or after recovery in a confirmed case. Intrapartum prophylactic antibiotic cover for
women with ante‐ or intrapartum risk factors for GBS is an alternative.
j
On presentation to triage areas, pregnant patients with TOCC risk factors should be
placed in an isolation room for further assessment.
k
Medical staff who are caring for suspected, probable or confirmed cases of COVID‐19
patients should be monitored closely for fever or other signs of infection and should
not be working if they have any COVID‐19 symptoms. Common symptoms at onset of illness
include fever, dry cough, myalgia, fatigue, dyspnea and anorexia. Some national health
authorities and hospital systems recommend that medical staff assigned to care for
suspected, probable or confirmed cases of COVID‐19 patients should minimize contact
with other patients and colleagues, with the aim of reducing the risk of exposure
and potential transmission.
l
Medical staff who have been exposed unexpectedly, while without PPE, to a COVID‐19‐infected
pregnant patient, should be quarantined or self‐isolate for 14 days.
m
Pregnant healthcare professionals should follow risk‐assessment and infection‐control
guidelines following exposure to patients with suspected, probable or confirmed COVID‐19.
KEY POINTS FOR CONSIDERATION
Pregnant women with confirmed COVID‐19 infection should be managed by designated tertiary
hospitals, and they should be informed of the risk of adverse pregnancy outcome.
Negative‐pressure isolation rooms should be set up for safe labor and delivery and
neonatal care.
During the COVID‐19 epidemic period, a detailed history regarding recent travel, occupation,
significant contact and cluster (i.e. TOCC) and clinical manifestations should be
acquired routinely from all pregnant women attending for routine care.
Chest imaging, especially CT scan, should be included in the work‐up of pregnant women
with suspected, probable or confirmed COVID‐19 infection.
Suspected/probable cases should be treated in isolation and confirmed cases should
be managed in a negative‐pressure isolation room. A woman with confirmed infection
who is critically ill should be admitted to a negative‐pressure isolation room in
the ICU.
Antenatal examination and delivery of pregnant women infected with COVID‐19 should
be carried out in a negative‐pressure isolation room on the labor ward. Human traffic
around this room should be limited when it is occupied by an infected patient.
All medical staff involved in management of infected women should don PPE as required.
Management of COVID‐19‐infected pregnant women should be undertaken by a multidisciplinary
team (obstetricians, maternal–fetal‐medicine subspecialists, intensivists, obstetric
anesthetists, midwives, virologists, microbiologists, neonatologists, infectious‐disease
specialists).
Timing and mode of delivery should be individualized, dependent mainly on the clinical
status of the patient, gestational age and fetal condition.
Both regional anesthesia and general anesthesia can be considered, depending on the
clinical condition of the patient and after consultation with the obstetric anesthetist.
At present, limited data suggest that there is no evidence of vertical mother‐to‐baby
transmission in women who develop COVID‐19 infection in late pregnancy.
There is currently insufficient evidence regarding the safety of breastfeeding and
the need for mother–baby separation. If the mother is severely or critically ill,
separation appears the best option, with attempts to express breastmilk in order to
maintain milk production. If the patient is asymptomatic or mildly affected, breastfeeding
and colocation (rooming‐in) can be considered by the mother in coordination with healthcare
providers.
Healthcare professionals engaged in obstetric care and those who perform obstetric
ultrasound examinations should be trained and fitted appropriately for respirators
and/or PAPR.
Following an ultrasound scan of a suspected, probable or confirmed COVID‐19‐infected
pregnant patient, surfaces of transducers should be cleaned and disinfected according
to manufacturer specifications, taking note of the recommended ‘wet time’ for wiping
transducers and other surfaces with disinfection agents.
AUTHORS
This Interim Guidance was produced
by:
L. C. Poon, Department of Obstetrics and Gynaecology, The Chinese University of Hong
Kong, Hong Kong
SAR
H. Yang, Department of Obstetrics and Gynecology, Peking University First Hospital,
Beijing, China
J. C. S. Lee, Department of Obstetrics and Gynaecology, KK Women's and Children's
Hospital, Singapore
J. A. Copel, Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School
of Medicine, New Haven, CT,
USA
T. Y. Leung, Department of Obstetrics and Gynaecology, The Chinese University of Hong
Kong, Hong Kong
SAR
Y. Zhang, Department of Obstetrics and Gynaecology, Zhongnan Hospital of Wuhan University,
Wuhan, China
D. Chen, Department of Obstetrics and Gynaecology, The Third Affiliated Hospital of
Guangzhou Medical University, Guangzhou, China
F. Prefumo, Department of Clinical and Experimental Sciences, University of Brescia,
Brescia, Italy
CITATION
This Interim Guidance should be cited
as: Poon LC, Yang H, Lee JCS, Copel JA, Leung TY, Zhang Y, Chen D, Prefumo F. ISUOG
Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium:
information for healthcare professionals. Ultrasound Obstet Gynecol 2020. DOI: 10.1002/uog.22013.