Obstetrics

Literature Review (Obstetrics): Gallery View, Grid View
Tool
: Information for Pregnant Patients About COVID-19 in 7 Different Languages (Pregistry)
Tool: PIH Flow Chart of Pregnancy Care During the COVID-19 Pandemic, From Screening and Triage Through Labor and Delivery to Postpartum Care.

Clinical Course in PregnancyCopy Link!

Clinical PresentationCopy Link!

Updated Date: February 2, 2021

Signs and SymptomsCopy Link!

In general, pregnant women present with signs and symptoms similar to the non-pregnant population (Zaigham; Wu et al; Liu et al; Afshar). In a study of 23,000 pregnant and 386,000 non-pregnant women with symptomatic COVID-19, the most frequently reported symptoms among pregnant women were cough (50%), headache (43%), muscle aches (37%), fever (32%), sore throat (28%), shortness of breath (26%), chills (24%), loss of taste or smell (22%), nausea or vomiting (20%), diarrhea (14%), runny nose (13%), fatigue (13%) and abdominal pain (8%). (Zambrano et al).

Asymptomatic and Presymptomatic InfectionCopy Link!

Rates of asymptomatic and pre-symptomatic infection amongst pregnant women vary in different studies. In one systematic review, 75% of positive mothers in universal screening were asymptomatic, and only 25% were symptomatic (Allotey et al). Depending on local epidemiology, prevalence in asymptomatic pregnant women may be high enough to warrant universal screening. See Screening. A series of 215 pregnant patients from New York demonstrated a 13.7% rate of positive nasopharyngeal swab testing for SARS-CoV2 amongst asymptomatic women (Sutton et al).

Differential DiagnosisCopy Link!

The clinical presentation for COVID-19 can mirror other diseases in pregnancy and other diseases can mimic COVID-19. Keep a broad differential.

  • If a patient is presenting with COVID-like symptoms, particularly a fever, a high clinical suspicion for alternative or comorbid processes such as chorioamnionitis, pyelonephritis, malaria, or influenza is needed.
  • Laboratory abnormalities may overlap with obstetric diagnoses (e.g. transaminitis and pulmonary findings can confound a diagnosis of preeclampsia or HELLP syndrome).
  • If a patient develops new signs / symptoms during hospitalization or labor, COVID-19 needs to be considered regardless of the likelihood of other common infectious processes (such as epidural fever or chorioamnionitis). In a study from two New York hospitals of 14 asymptomatic patients with positive SARS-CoV2 nasopharyngeal swabs admitted to labor and delivery for obstetric indications, 8 developed fever while inpatient as their only COVID symptom, while 2 developed severe disease requiring ICU care (Breslin et al).

Maternal OutcomesCopy Link!

Updated Date: August 23, 2021
Literature Review:
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Severe disease and ICU admission:

Pregnant women are at increased risk of severe disease compared to the general population (ACOG COVID–19 FAQs). That said, most pregnant women present with mild disease, and critical disease is uncommon. In a study of 23,000 pregnant and 386,000 non-pregnant women with symptomatic COVID-19, the pregnant patients were more likely to be admitted to the ICU (10.5 versus 3.9 per 1000 cases, RR 2.9), end up on a ventilator (2.9 versus 1.1 per 1000 cases, aRR 2.9), or die (1.5 versus 1.2 cases per 1000, aRR 1.25) (Zambrano et al). A metanalysis of 192 studies comprising over 67,000 patients likewise showed ICU admission OR of 2.13, Invasive ventilation OR of 2.59, and need for extracorporeal membrane oxygenation OR of 2.02, and maternal death OR 2.85 (Allotey et al.) Another systematic review of 77 studies including over 11,000 pregnant and postpartum women also showed that those with COVID-19 disease had higher relative risk of ICU admission (1.62, 1.33 to 1.96) and need for invasive ventilation (1.88, 1.36 to 2.60) (Allotey et al).

Obstetric OutcomesCopy Link!

Updated Date: August 23, 2021
Data on first and second trimester infections with COVID-19 are limited. Most of the current data are on women infected in the third trimester and most studies were conducted in high-resource settings.

Pre-eclampsia:

In one metanalysis of 42 studies comprising over 438,000 pregnant people, COVID was associated with an OR of 1.33 for pre-eclampsia. Compared with mild disease, severe disease was strongly associated with preeclampsia (OR 4.16). (Wei et al)

Preterm birth and cesarean sections: Current data suggests that maternal SARS-CoV2 infection increases the risk of preterm spontaneous birth, induced delivery, and Cesarean delivery.

  • A metanalysis of 42 studies comprising over 438,000 pregnant people found that COVID was associated with an OR of 1.82 for preterm birth. Compared with mild disease, severe disease was strongly associated with preterm birth (OR 4.29). (Wei et al)
  • A meta-analysis of 17 studies from the US, Europe, China, and Brazil showed that approximately one fifth of the infants of mothers with SARS-CoV2 infection were born preterm (mostly medically-induced preterm delivery, not spontaneous), and nearly half were born by Cesarean (Khalil et al). In a U.S. study of 3900 infants born to mothers with SARS-CoV2 infection, more of the infants were born preterm than the national average (12.9 versus 10.2 percent.) (Woodworth et al).
  • In contrast, among 263 infants initially enrolled in the PRIORITY study, no difference in adverse outcomes, including preterm birth, NICU admission, and respiratory disease, were found (though Black and Latina women were underrepresented in this study, Flaherman, 2020). A more diverse cohort of 252 SARS-CoV2-infected pregnant women and 3122 negative pregnant in Dallas also suggested no differences in a composite outcome of preterm birth (RR 1.02, (95% CI 0.70-1.48), preeclampsia with severe features, or cesarean for abnormal fetal heart rate (Adhikari et al).

Effect of disease severity: Obstetric outcomes may be affected by severity of maternal disease. In a cohort of women with severe/critical disease, at least 50% delivered preterm (amongst the subset with critical disease this was > 80%), most of these via Cesarean section (Pierce-Williams et al).

Fetal OutcomesCopy Link!

Updated Date: August 23, 2021
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Miscarriage (Spontaneous Abortion) and StillbirthCopy Link!

In a metanalysis of 42 studies comprising over 400,000 people who were pregnant, COVID infection was associated with an Odds Ratio of 2.11 for stillbirth. (Wei et al) There is less consistent data about spontaneous first trimester abortion or miscarriage. One small study suggests no association, but is very limited by sample size (Cosma et al).

Notably there is no data suggesting an association of miscarriage or infertility with COVID vaccines. See vaccines in pregnant women.

Placental Perfusion and IUGRCopy Link!

Placental changes from maternal SARS-CoV2 infection could possibly increase the risk of intrauterine growth restriction. In a case series including 16 placentas of patients with COVID-19 disease, decidual arteriopathy secondary to maternal vascular malperfusion was more likely to be identified in placentas from COVID patients compared to historical controls (Shanes et al). However, in a study that included 252 infants of infected mothers, placental pathologic abnormalities were not associated with disease severity and there was no difference in the rate of small for gestational age (SGA) (Adhikari et al).

PrematurityCopy Link!

See Obstetric Outcomes

Neonatal Outcomes and NICU AdmissionCopy Link!

Data on neonatal outcomes, as with prematurity, has been conflicting and may be severity-related. However, in one metanalysis of 192 studies comprising 67,000 pregnancies, it appears that COVID infection is associated with higher rates of NICU admission (OR 4.89). (Allotey et al).

Vertical Transmission and Neonatal OutcomesCopy Link!

See Vertical Transmission (Pediatrics)

Antenatal CareCopy Link!

Updated Date: February 2, 2021
Literature Review (Prenatal Care): Gallery View, Grid View

Screening and TestingCopy Link!

ScreeningCopy Link!

All pregnant patients should be screened for symptoms of COVID-19 at, and ideally before, each visit.

Why screen?: Symptom screening and selected testing of asymptomatic and symptomatic pregnant women is recommended to:

  1. Identify cases early and establish a plan to monitor for symptom progression and how to seek care if needed
  2. Decrease transmission to other patients and healthcare providers during in-person visits, and to determine suitability for in-person versus virtual care
  3. Plan for the personnel, equipment, and rooms needed if there is a chance the patient will be COVID-positive during labor and delivery
  4. Educate patients about decreasing transmission to family living in the same space (including the new neonate, where relevant)

Symptom Screening: Symptom screening can be conducted over the phone, ideally 24 hours before the patient presents for care, and should occur again upon arrival at the facility. See Symptom Screening. Patients who screen positive should still receive all indicated services but should be treated as COVID-19 PUI.

Tool: PIH Obstetric and COVID-19 Screening & Triage Algorithm

TestingCopy Link!

Asymptomatic patient testing: Testing criteria vary by institutional protocol and resource availability. Currently the BWH model is to test the following asymptomatic patients:

  1. All pregnant patients on admission to Labor and Delivery (some institutions, like UCSF, repeat this testing every 4 days if admitted for this long).
  1. Currently accompanying support person is not tested
  1. All planned admissions for scheduled induction of labor or cesarean delivery
  2. Patients with exposure to a person with respiratory illness or known COVID (see COVID exposures).
  1. If the exposure is not confirmed to be COVID and there is a significant possibility that it could be influenza, consider influenza testing and prophylaxis.

Symptomatic testing: All obstetric patients with symptoms of COVID should be tested.

  1. Patients with mild illness can be referred for outpatient testing at any designated testing site.
  1. If testing is negative: Consider testing for comorbid conditions such as malaria, RSV, and influenza and treating (empirically or otherwise) if indicated. Consider repeat COVID testing if the patient has worsening symptoms.
  2. If testing is positive: if the patient has only mild symptoms and no major comorbidities and is able to follow up with care then the patient can be managed at home (ACOG and SMFM, Outpatient Assessment and Management).
  1. Patients with comorbidities chronic lung/heart/kidney/liver disease, mod-severe asthma, immunocompromised, obesity, diabetes, psychiatric or substance use disorder or any concerning signs for moderate or severe disease, dyspnea or chest pain, Sp02 <94%, RR >30 should be evaluated and tested in person (Poon et al).
  1. See Severity Assessment

Routine Antenatal CareCopy Link!

Visit FrequencyCopy Link!

Due to the risk of asymptomatic transmission of COVID-19, some institutions are changing routine outpatient care to protect women and their families from facility-based transmission. The WHO Focused Antenatal Care Model recommends a minimum of 4 antenatal visits which cluster risk assessments, screenings, distribution of essential medications, and essential patient education about obstetric danger signs. Although not officially endorsed by the American College of Obstetricians and Gynecologists (ACOG), there are published guidelines for routine antenatal care during the SARS-CoV2 pandemic (Boelig et al), and the Society for Maternal Fetal Medicine has published guidelines for modified ultrasound frequency (SMFM Ultrasound Practice Suggestions). Exact practice patterns will depend on available resources, patient medical complexity, local epidemiology, and provider discretion.

It is also important to note that prenatal care can be provided safely in-person when appropriate precautions and safety measures are used. Women should be counseled that it is still essential to obtain care throughout pregnancy to ensure the health of the patient and her fetus.

Patients with Low Risk of Obstetric ComplicationsCopy Link!

Gestational age

Visit type

FIGO Recommendations

MFM Guidelines (Boelig et al.)

<11 weeks

Telephone

OB Intake (History-taking)

~12 weeks

In Person

History-taking

Assessment for risk-factors and comorbidities relevant to COVID-19

Routine labs

Genetic screen if available

Ultrasound if available for dating and nuchal translucency

Initial OB labs

Ultrasound, if available, for dating +/- nuchal translucency

16 weeks

Telephone

~20 weeks

In Person

Routine care

Anatomy scan, if available (at 19-20 wks, favor 20 wks in high BMI patients)

Routine care

Anatomy ultrasound

~24 weeks

Telephone or as needed

Consider checking BP at home or ambulatory setting if possible

Oral glucose tolerance test

~28 weeks

In person

Routine care

Rhogam, if applicable

TDaP if applicable

Routine care

Labs/vaccines

30 wks

Telephone

Consider checking BP at home or ambulatory setting if possible

32 weeks

In person

Ultrasound for placental location if low-lying placenta or placenta previa on prior ultrasound/ growth scan as per local practice

Repeat ultrasound as indicated

34 weeks

Telephone or PRN

Consider checking BP at home or ambulatory setting if possible

36 weeks

In person

Routine care

GBS swab as indicated

Repeat ultrasound as indicated

GBS swab, repeat HIV screen

37-41 weeks

Telehealth

Recommended in-person at 38 wks in FIGO schedule

Routine care and kick counts weekly

Postpartum

Telephone or PRN

High risk may require in-person visit

See Poon et al (algorithm #1) and FIGO Global Interim Guidance: Safe Motherhood and COVID-19

Patients with Intermediate Risk of ComplicationsCopy Link!

Hypertension not on medication, gestational diabetes or pregestational diabetes not on medication, advanced maternal age > 40 years old, BMI > 35, uncomplicated dichorionic diamniotic twin pregnancies, history of intrauterine growth restriction (IUGR), or preeclampsia in a prior pregnancy are considered intermediate risk. We generally recommend a similar approach to first and second trimester screening as low-risk patients plus the following for specific conditions;

  • History of IUGR or pre-eclampsia in a prior pregnancy: Ultrasound for estimated fetal weight at 30-32 weeks. Repeat ultrasound every 6 weeks. (Identification of IUGR places patient in high risk category, see below)
  • Dichorionic Twins: Ultrasound every 4 weeks for fetal growth beginning at 28 weeks.
  • Diet-Controlled Pregestational Diabetes or Gestational Diabetes: Third trimester ultrasound for assessment of fetal weight at discretion of care provider
  • Fetal Anomalies: Growth surveillance tailored to fetal anomaly with more frequent surveillance in the face of hydrops, polyhydramnios, or concern for genetic syndrome
  • Short Cervix but > 2.5 cm: Monitor cervical length every 2 weeks until 28 weeks if cervical length remains stable.
Patients with Higher Risk of ComplicationsCopy Link!

Hypertension on medications, gestational hypertension, pregestational or gestational diabetes on medications, monochorionic twins and higher-order multiples, IUGR in the current pregnancy, preeclampsia, maternal renal disease, other complex maternal or fetal comorbidities are considered higher risk for complications. Patients with other prior medical conditions, or who develop complications during pregnancy, may also be included in this category per provider discretion. These patients require additional surveillance during pregnancy and may develop additional morbidity if care is rationed or deferred. The frequency of antenatal visits and fetal surveillance during pregnancy depends on specific conditions and available resources, and not all the following may be available in every setting.

In addition to standard antenatal care, in settings where antenatal testing is available, consider the following:

  • Hypertension or diabetes: Growth ultrasound every 6 weeks with weekly non-stress tests (NSTs) for interval fetal testing.
  • Monochorionic twins: Ultrasounds every 2 weeks to monitor for evidence of twin-to-twin transfusion syndrome.
  • IUGR: Weekly NSTs with biophysical profile (BPP) and umbilical artery Doppler every 4 weeks in place of NST. Increase NSTs to twice weekly in the setting of abnormal Dopplers.
  • Short Cervix < 2.5 cm before 25 weeks: Weekly ultrasound for cervical length at the discretion of the OB care provider until 25 weeks. A final cervical length ultrasound can be considered after cerclage placement.

Obstetrical ReferralCopy Link!

Referral to obstetrical care for patients cared for by Community Health Workers, midwives, and other practitioners should continue based on the usual indications. Community Health Workers (CHWs) are important for the identification of cases needing referral in the community. A framework for establishing roles of CHWs during COVID-19 is discussed here. Patients with symptomatic COVID-19 may not be appropriate for delivery in all facilities. Institutions without both critical care and obstetrical care services and the necessary PPE and oxygen support should prepare for transferring severe cases of COVID-19 in pregnant women.

Social Screening and Patient EducationCopy Link!

Social screenings remain an essential service, perhaps more than ever given the frequency of economic and food insecurity during pandemic. Providers should provide referrals to food and economic assistance where available. In addition, economic instability and home quarantine/isolation may contribute to increased rates of intimate partner violence and/or child abuse, as well as unplanned pregnancy. Clinical providers should continue to screen patients for these conditions and provide referral when appropriate.

Patient education should include the following:

  • Anticipatory guidance about pregnancy/childbirth.
  • Coronavirus-related changes being made to visit schedules or care protocols (including infection prevention measures)
  • Ways to protect themselves from contracting coronavirus at home and in the community (see Transmission Prevention)
  • Information on how to contact a maternity provider (their own obstetrician if they are followed by a single doctor, or a provider at their antenatal clinic or maternity ward) with questions or symptoms
  • Review of obstetric and COVID danger signs with advice on when to seek care
Danger signsCopy Link!

COVID-19 Danger Signs

Obstetric Danger Signs

Difficulty breathing/shortness of breath

Bluish lips or extremities

Gasping for air when speaking

Coughing up blood

Pain/pressure in chest when NOT coughing

Dizziness when standing

Altered mental status or severe sleepiness

Inability to eat/drink or walk

Labor pains

Rupture of membranes

Vaginal bleeding

Decreased fetal movement

Severe headache

Visual changes

Convulsions

Persistent fever

Unexplained abdominal pain

COVID VaccinationCopy Link!

The COVID-19 vaccines currently available have not been tested in pregnancy and thus there is no current safety data specific to pregnancy. There is also no data that indicates the vaccine should be contraindicated in pregnancy. For more information see vaccines.

  • ACOG and SMFM state that COVID-19 vaccines should not be withheld from pregnant individuals or lactating individuals who meet current vaccination criteria.
  • Patients should be provided with information about vaccine safety, efficacy, side effects and the limitations based on the current data we have.
  • Vaccination is strongly encouraged for those individuals who are trying to conceive or considering pregnancy and who meet vaccine eligibility criteria.
  • A pregnancy test is NOT required prior to COVID-19 vaccine administration.

Treating COVID in PregnancyCopy Link!

Updated Date: February 2, 2021
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Antenatal MonitoringCopy Link!

Patients with COVID-19 infection (at any point in their pregnancy) should receive increased fetal surveillance as we do not yet know the impact of infection on fetal development. There is not yet standard guidance on this, though BWH will often suggest:

  1. Growth ultrasound surveillance starting when the pregnancy is at 24 weeks, and continuing every 3-4 weeks until delivery
  2. Weekly fetal nonstress test beginning when the pregnancy is at 32-34 weeks until delivery. (Can use biophysical profile at the times of growth surveillance ultrasounds in lieu of nonstress tests to reduce unnecessary testing.)

Clinical Severity AssessmentCopy Link!

See Acuity Triage and Disease Severity and Disposition for advice on the appropriate care location for patients in general. The initial assessment of pregnant women should include assessment of gestational age and fetal well-being. For telephonic triage, this includes verbal assessment of fetal movement; for in-person assessment, fetal heart rate monitoring should be performed as appropriate for gestational age.

Pregnant women, due to both younger age and physiologic adaptation, can compensate for medical illness in a way that masks its severity until their physiologic reserves are suddenly exhausted. Classically, they will appear quite well until they rapidly deteriorate. Suggested criteria for observation or admission are as follows. The appropriate admission or observation location (e.g. medical ward, labor and delivery, or intensive care unit) should be made in conjunction with the obstetric care team and depending on local policies:

Triage assessments that may be possible at home or in healthcare settings:

  1. COVID-19 danger signs and Obstetric danger signs
  1. Even patients with mild COVID may warrant admission for obstetric indications
  1. SpO2 < 94% or <92% with exertion on room air if a pulse oximeter is available.
  2. Blood pressure abnormalities if a BP monitor is available
  1. Hypotension (typically systolic < 90 or diastolic < 50, unless baseline blood pressure is below these criteria in the prior antenatal record)
  2. Hypertension (typically systolic > 140 or diastolic pressure > 90 on two separate measurements four hours apart in the absence of chronic hypertension)
  1. Persistent fever > 38°C (101°F) despite antipyretic
  2. Respiratory rate > 30
  3. Maternal tachycardia > 120 (not improved with fluids if in healthcare setting)

Triage assessment in healthcare settings:

  1. Lab abnormalities including transaminitis, elevated creatinine, or new thrombocytopenia < 150K
  2. Category 2 fetal heart rate on tracing (or, if unavailable, on intermittent auscultation) despite adequate maternal resuscitation.
  1. For tracings: see criteria from Bailey et al
  2. For intermittent auscultation: See criteria from American College of Nurse-Midwives
  1. The presence of maternal or fetal comorbidities:
  1. Maternal examples may include pulmonary disease, heart disease, diabetes, HIV infection, or hypertension including preeclampsia.
  2. Fetal examples include intrauterine growth restriction, monochorionic twin pregnancy, or other markers of placental insufficiency.

Intermittent Auscultation of Fetal Heart RateCopy Link!

This technique can be used if continuous fetal monitoring is unavailable (American College of Nurse-Midwives).

  1. First auscultate FHR between contractions and when the fetus is not moving. At the same time, assess the mother's radial pulse to ensure that the FHR is auscultated and not the mother’s.
  2. After establishing the baseline rate, auscultate the FHR for 15 to 60 seconds at various intervals depending on the stage of labor.
  1. If not in labor or in latent phase, every 30 to 60minutes.
  2. In active labor, every 15 to 30 minutes
  3. In second stage, every 5 to 15 minutes)
  1. Non-reassuring findings include the presence of any of the following:
  1. Irregular rhythm
  2. Presence of FHR decreases or decelerations from the
  3. baseline
  4. Tachycardia (sustained FHR above 160bpm for >10 minutes in duration)
  5. Bradycardia (sustained FHR below 110bpm for >10 minutes in duration)

Mild Illness (Outpatient)Copy Link!

Updated Date: February 2, 2021

Care for pregnant COVID-19 patients with mild disease largely mirrors that of the general population. See also Home and Outpatient Management.

  • Symptomatic management is appropriate for mild cases of confirmed or suspected COVID-19.
  • Educate patients about Isolation, as well as COVID and obstetric warning signs.
  • Maintain adequate oral hydration
  • Patients should ideally receive follow-up telephone contact by a provider within 48 hours after initial diagnosis, and then on a regular schedule based on risk thereafter.
  • Therapeutics specific to COVID-19 disease in pregnancy are discussed below.

Moderate or Severe Illness (Inpatient)Copy Link!

Updated Date: February 2, 2021

Compared to other patients, there are some minor modifications in the care of pregnant patients with moderate or severe COVID-19, including a higher target oxygen saturation and different considerations for proning. See also Inpatient Management for general adult management guidelines.

  • All women on admission to the maternity ward should identify someone to make healthcare decisions in the event that they are unable to (healthcare proxy) and communicate goals of care.
  • For patients with moderate or severe disease, routine care, including imaging (with shielding where possible) should not be withheld due to pregnancy.
  • If antibiotic treatment is administered, antibiotics contraindicated in pregnancy (e.g. tetracyclines, fluoroquinolones) should be avoided.
  • In cases of maternal hypoxia, given the benefits of proning, a supported prone position or Lateral Sims can be used, with cushioning used to avoid direct pressure on the abdomen (Halscott et al).
  • Target oxygen saturation for pregnant women is 95% or greater.
  • Discharge planning should involve follow-up with a maternity care provider within 48 hours, and then on a regular schedule based on risk thereafter, and increased antenatal monitoring.

Critical IllnessCopy Link!

Updated Date: February 2, 2021

ManagementCopy Link!

Most management of the critically-ill pregnant patient is unchanged from that of the general population (see Critical Care Management), but differences exist.

  1. Team: Given the need for fetal monitoring and potentially for urgent delivery, care should ideally include a multidisciplinary critical care and obstetrics team in the location that makes the most sense based on the patient’s anticipated clinical needs. Neonatology if available should be notified of any pregnant patient admitted to the hospital at or beyond 22 weeks.
  2. Physiologic targets: Modifications from standard care should reflect the physiologic changes of pregnancy including:
  1. Increased cardiac output (heart rate and stroke volume)
  2. Decreased systemic vascular resistance
  3. Increased minute ventilation (driven by respiratory rate)
  4. Physiologic compensated respiratory alkalosis
  5. Decreased pulmonary functional residual capacity
  6. Increased GFR and volume of distribution
  7. Expanded plasma volume
  8. Alterations in clotting cascade to promote coagulation
  1. Intubation should be discussed earlier than for an equivalent non-pregnant patient given increased airway edema and aspiration risk in pregnancy as well as limited functional residual capacity.
  1. Ventilation should target the respiratory alkalosis of pregnancy maintaining a pCO2 < 45 and a pH > 7.35. Permissive hypercapnia may be acceptable but inability to maintain these targets alongside other standards of care for lung-protective ventilation should prompt a discussion with the obstetric care team. Depending on the gestational age and clinical status, this may prompt more liberal parameters, additional fetal monitoring, or consideration of delivery.
  1. Prone positioning in pregnancy has been reported and should be considered for standard indications (Dennis et al). See Proning. A supported prone position or Lateral Sims can be used, with cushioning used to avoid direct pressure on the abdomen (Halscott et al). Early discussion of the feasibility of this strategy and gestational-age dependent patient positioning considerations should take place with the obstetric team.
  2. Steroids: Require balancing fetal and maternal needs, see Therapeutics in Pregnancy.
  3. Fetal monitoring: A plan for fetal monitoring should be established by the obstetric team. Fetal status may be evaluated twice daily (via non-stress test, if available) with increased frequency if alterations in fetal status are identified. Spontaneous preterm birth rates in critically-ill populations are very high. The obstetrics team should share anticipated outcomes at a given gestational age with the critical care team to inform their management.

Tool: BWH Quick Tips for Intensivists Caring for Critically Ill Obstetric Patients
Tool: Prone Positioning for Pregnant Women With Hypoxemia Due to COVID-19 (Tolcher et al)

Delivery in Critically Ill PatientsCopy Link!

  1. When to call obstetrics: Fetal distress or unexplained maternal tachycardia, hypertension, increasing sedation requirements, or tachypnea require obstetric evaluation for possible preterm labor. See also Tocolysis.
  1. Contraindications to labor (e.g. placenta previa, prior uterine surgery, in some settings nonvertex presentation) should be noted prominently in the patient’s chart and birth plan
  1. Equipment: A vaginal delivery kit, cesarean delivery kit, and neonatal warmer and resuscitation kit should be at the bedside in anticipation of spontaneous delivery or maternal cardiac arrest for all patients.
  2. Planning for emergent delivery: The multidisciplinary team should all be aware of the pathway for emergent delivery for emergent maternal or fetal indications based on gestational age and maternal stability.
  3. Planning for urgent or scheduled delivery: Delivery may become necessary in select circumstances where oxygenation or ventilation are thought to be impaired by pregnancy.
  1. Anticipate the autotransfusion after delivery as blood returns from the uterus into the circulation. Diuresis and PEEP optimization may be needed.
  2. Vaginal delivery is the preferred mode of delivery for patients in the absence of contraindication to labor. The decision for vaginal versus Cesarean delivery in the critically-ill patient should be individualized taking into account parity, gestational age, monitoring needs, and likelihood of a successful vaginal birth.

Cardiac ArrestCopy Link!

Maternal cardiac arrest at or beyond 20 weeks, or when the uterus is at the level of the umbilicus, includes specific modifications to account for the impact of the gravid uterus (Jeejeebhoy et al).

  1. Provide immediate left uterine displacement by either pushing or pulling the uterus off the IVC.
  1. This is a dedicated role for a member of the code team.
  1. Ensure the IV used for code medications is above the level of the diaphragm to ensure no interference with return to circulation.
  2. Remove and detach all fetal monitors.
  3. Prepare to begin a resuscitative hysterotomy (perimortem Cesarean delivery) if 4 minutes elapse without return of spontaneous circulation (ROSC) with goal for delivery of the fetus by 5 minutes after the cardiac arrest.

Labor and Delivery for COVID PatientsCopy Link!

Updated Date: February 2, 2021
Literature Review: Gallery View, Grid View

Care of COVID-19 patients during labor generally follows routine protocols, with minor modifications, but should include increased maternal and fetal monitoring. See Infection Control in Obstetric Settings for details on infection control measures.

LaborCopy Link!

Support PersonCopy Link!

WHO recommends women have a companion of their choice with them during childbirth as part of supporting women’s rights to a “safe and positive childbirth experience” (World Health Organization). We recommend that women should be allowed a screened, asymptomatic support person. The support person must wear a mask and refrain from walking around the ward.

Maternal AssessmentCopy Link!

Assess severity of COVID-19 symptoms at minimum every 4 hours. In case of deterioration, make an individualized assessment regarding the risks and benefits of continuing labor vs proceeding with an emergency Cesarean.

Fetal Monitoring and AmniotomyCopy Link!

Consider continuous electronic fetal monitoring, where available

  • Internal monitors (fetal scalp electrodes, intrauterine pressure catheters) may be used for usual indications, given that current data thus suggest only maternal-to-fetal placental transmission of SARS-CoV2 and the virus has not been reliably isolated in amniotic fluid (see placental transmission).
  • Amniotomy may still be utilized for labor management as clinically indicated (SMFM and SOAP Labor and Delivery Considerations)

Labor AnalgesiaCopy Link!

  • Nitrous oxide: Some institutions avoid nitrous oxide in COVID+ patients due to risk of aerosolized infectious droplets and risk of viral contamination of the breathing system and equipment. There is variability in practice and if used, adequate PPE and a bacterial viral filter should be used.
  • Remifentanil PCA: There is no data currently to guide practice in COVID19, but should be used with caution due to risk of respiratory depression, especially in women with respiratory symptoms or need for supplemental oxygen.
  • Neuraxial analgesia: Recommended for standard indications to laboring women. May confer additional benefit in women with COVID-19 as the ability to rapidly convert the epidural to surgical anaesthesia in the event of operative delivery being required would potentially avoid the need for general anesthesia, which is a risk to the patient and also an aerosol generating procedure.
  • Other practices are generally the same as for non-COVID patients (Bampoe et al).

TocolysisCopy Link!

If antenatal corticosteroids are administered, tocolysis can be administered until completion. Tocolysis is not contraindicated in SARS-CoV2 infection, but the choice is highly individualized, weighing the fetal benefit of slowing spontaneous preterm labor (more acute at certain gestational ages) against the potential maternal side effects of the individual agents. In preterm labor, intraamniotic infection may need to be ruled out before using tocolysis. Ruptured membranes are a contraindication.

  • Indomethacin can be used in most cases until 32 weeks.
  • Nifedipine is a commonly used tocolytic from 32-34 weeks. Caution that using magnesium sulfate and a calcium channel blocker concomitantly can lead to decreased muscle contractility and can worsen respiratory depression. Caution must be used in pregnant patients requiring oxygen as nifedipine is a potent systemic and pulmonary vasodilator that can worsen hypotension or V/Q mismatch. Nifedipine is contraindicated for women with cardiac manifestations of COVID.
  • Magnesium Sulfate is not the tocolytic of choice for SARS-CoV2 infected patients who do not have an additional indication (e.g. fetal neuroprotection, seizure prophylaxis).

Magnesium SulfateCopy Link!

Magnesium sulfate is routinely used for both fetal neuroprotection and preeclampsia/seizure prophylaxis. In SARS-CoV2 infected patients without respiratory symptoms, it should be used for the usual obstetric indications. For patients with respiratory symptoms, the benefits of therapy should be weighed against potential risks of maternal respiratory depression (less relevant if the patient is intubated). If renal function is impaired, doses should be adjusted accordingly.

  • Respiratory depression typically occurs at serum concentrations of 10-13 mg/dL and will be preceded by loss of deep tendon reflexes often occurring at levels of 7-10 mg/dL.
  • A single 4-gram bolus of magnesium sulfate without subsequent infusion may serve as an alternative to usual dosing in the setting of mild respiratory distress.

DeliveryCopy Link!

Updated Date: February 2, 2021

Timing of DeliveryCopy Link!

  • Timing and mode of delivery should be individualized based on clinical status of the patient, gestational age, and fetal condition. While COVID-19 itself is not an indication for delivery, elective delivery at 39 weeks or greater can be considered given the uncertain impact of COVID-19 infection on fetal outcomes.
  • Medically indicated deliveries should not be delayed in an individual who is COVID-19 positive.
  • If a woman requires ventilatory support, it may be reasonable to expedite delivery via induction or Cesarean delivery as it may be more difficult to ventilate with a gravid uterus.

Mode of DeliveryCopy Link!

  • Vaginal delivery is not contraindicated. There is no evidence that suggests women with suspected or confirmed COVID-19 cannot give birth vaginally or would be safer having a Cesarean section or operative vaginal delivery.
  • Operative Delivery: Data on perinatal transmission at this time does not preclude the use of forceps or vacuum.
  • Cesarean Delivery:
  • Cord Clamping: Delayed cord clamping has known neonatal benefits. Given the lack of evidence of significant vertical transmission of SARS-CoV2, delayed cord clamping is not contraindicated.
  • Placental tissue and miscarried embryos/fetuses should be treated as infectious tissues and disposed of appropriately.

Neonatal ResuscitationCopy Link!

Respiratory distress in a neonate can have a variety of etiologies, including perinatal COVID-19 transmission, prematurity, sepsis, and asphyxia. Treatment therefore should be based on clinical presentation. COVID-19 testing is not routinely performed in infants. If performed, testing should be delayed to 24-48 hours of life as maternal secretions can cause false positivity; a follow-up test should be performed at 48-72 hour intervals. Throat and nasopharyngeal swabs are generally used (Puopolo et al).

Further management of COVID-19 exposed infants is reviewed in the Pediatric section.

Postpartum CareCopy Link!

Updated Date: February 2, 2021

BreastfeedingCopy Link!

See Breastfeeding (Pediatrics)

Skin-to-Skin ContactCopy Link!

There are significant benefits to mother/newborn skin-to-skin contact including mother-infant bonding, increased success with breastfeeding, and stabilization of infant glucose levels and body temperature. However, neonates may be at increased risk for severe infection (see pediatric severity). Shared decision-making is recommended. It is reasonable to counsel a mother to practice skin-to-skin contact with her baby, while wearing a mask and after handwashing (World Health Organization). See also breastfeeding and distancing for infected caregivers.

ContraceptionCopy Link!

Given decreased in-person contact with the healthcare system during COVID-19, offer postpartum contraception (especially long-active reversible contraceptives and progesterone-only methods) and initiate prior to discharge if the patient desires.

Pain ControlCopy Link!

Pain control is per provider preference. Non-steroidal anti-inflammatory drugs (NSAIDs) may be used and are safe in breastfeeding for most patients. Currently there is no evidence of severe adverse effects in patients with COVID-19 as a result of the use of NSAIDs.

Hospital DischargeCopy Link!

  • Timing of discharge depends on the clinical status of mother and newborn, the mode of delivery, and the ability to isolate safely.
  • Teaching: In addition to routine counseling, patients should be taught about handwashing/physical distancing, postpartum depression, and COVID-19 signs/symptoms, and should be screened for the need for social or economic support.
  • Follow-up:
  • For mild disease, full visit (by phone/video if possible) within a week after discharge.
  • For moderate or severe disease, check-up call from a healthcare provider within 48 hours after discharge and a full visit (by phone/video if possible) a week after discharge. These patients should also be offered home community health worker or nursing services for monitoring of symptoms and vital signs.

Therapeutics in PregnancyCopy Link!

Symptomatic TreatmentsCopy Link!

Updated Date: February 2, 2021

  • Acetaminophen/paracetamol: Fever may be associated with an increased rate of birth defects, especially neural tube defects, We recommend acetaminophen for pregnant women with a temperature ≥ 100.40F, up to 1000mg in a single dose, not to exceed 3000mg in 24 hours. Acetaminophen is also the preferred antipyretic for influenza in pregnancy (ACOG Guidance on the Assessment and Treatment of Pregnant Women with Suspected or Confirmed Influenza; SMFM, Am J Obstet Gynecol). Nonsteroidal anti-inflammatories should be avoided during pregnancy (though not for COVID reasons).
  • Cough suppressants: Guaifenesin and dextromethorphan are safe in pregnancy.

Thrombosis ProphylaxisCopy Link!

Updated Date: February 2, 2021

Severe COVID-19 infection and pregnancy are both independent risk factors for thrombosis. Thrombosis in pregnancy is especially common in the third trimester and postpartum and can contribute to severe morbidity and mortality.

  • Outpatients: There are no universal practices on VTE prophylaxis for outpatients. Non-pregnant outpatients typically are not treated with any thromboprophylaxis. Low-dose aspirin is safely used in pregnancy for several indications, most commonly in preventing preeclampsia (ACOG Guidance on Low-Dose Aspirin Use During Pregnancy).
  • Inpatients: Different institutions adopt standard or intermediate-dosing thromboprophylaxis. Generally pregnant women are treated with the same regimens as non-pregnant patients at most institutions.
  • Postpartum patients: Some post-partum patients may merit prophylactic anticoagulation after delivery. This is very practice- and patient- specific, depending on risk factors, mode of delivery (surgical or vaginal), and patient mobility. Expert guidance is mixed or absent. The Royal College of Obstetricians and Gynecologists recommends 10 days of thromboprophylaxis post-discharge for pregnant patients or postpartum patients within 6 wks of discharge who have been admitted for COVID-19 (RCOG)

Systemic CorticosteroidsCopy Link!

Updated Date: February 2, 2021

Corticosteroid treatment in pregnancy must balance maternal COVID recovery and fetal lung maturation with the desire to minimize unnecessary fetal exposure. Certain corticosteroids (methylprednisolone, prednisone, prednisolone, and hydrocortisone) have limited placental transfer and can be used to treat the mother but limit fetal exposure.

Corticosteroids for COVID: A 10-day course of corticosteroids is recommended for adults with an oxygen requirement due to COVID-19 infection.

Corticosteroids for Fetal Lung Maturity: A 48-hour course of corticosteroids is recommended for fetal lung maturity between 24+0 and 33+6 weeks of gestation in patients at high risk of preterm birth within seven days.

Recommendations:

  1. If a patient requires corticosteroids for both fetal lung maturity and COVID (generally in weeks 24-33 6/7)
  1. Dexamethasone 6mg IM q12h x 4 doses. (This high dose is for fetal lung maturation.)
  2. After the initial 48 hours of dexamethasone, many patients can be switched to hydrocortisone, methylprednisolone, or prednisone to reduce fetal exposure.. See Corticosteroids for dosing. The RECOVERY trial in the U.K. (the initial study proving the utility of dexamethasone in COVID-19 patients with an oxygen requirement) used prednisolone 40 mg administered by mouth daily or hydrocortisone 80 mg IV twice daily for pregnant patients. Recovery Collab, NEJM 2020.
  1. If a patient meets criteria for corticosteroids because of COVID but does not require corticosteroids for fetal lung maturity (generally < week 24 or > week 34)
  1. Recommend hydrocortisone, methylprednisolone, or prednisone to minimize passage to the fetus.
  1. If a patient meets criteria for corticosteroids for fetal lung maturity, but not for COVID, recommendations remain the same as for non-COVID patients
  1. Betamethasone 12 mg IM Q24 hours for two doses
  2. Dexamethasone 6mg IM q12h for four doses.
  1. Only betamethasone or dexamethasone should be used as other options do not adequately transfer across the placenta
  1. If a non-breastfeeding postpartum patient meets criteria for corticosteroids for COVID
  1. Recommendations remain the same as for a non-pregnant COVID patient.
  1. If a breastfeeding postpartum patient meet meets criteria for corticosteroids for COVID
  1. Recommend methylprednisolone, prednisone, prednisolone, or hydrocortisone. See Corticosteroids for dosing.

Other Therapeutics in PregnancyCopy Link!

Updated Date: February 2, 2021

  • Remdesivir: Data is limited in pregnancy. Pregnancy was an exclusion criterion for participation in the initial remdesivir trials for COVID-19. A retrospective review of 86 pregnant and postpartum women who did receive remdesivir recorded serious adverse events in 16%, generally Grade 3 transaminase elevations, generally thought to be related to underlying disease, (though remdesivir can cause transaminitis.) One mother died of underlying disease; there were no neonatal deaths (Burwick R et al). There is no known fetal toxicity with remdesivir. SMFM recommends this be offered to pregnant patients who meet criteria.
  • Immunomodulators: Anti-IL6 Agents (Tocilizumab, Siltuximab, Sarilumab). Tocilizumab does cross the placenta. Post-marketing data analysis of pregnancy outcomes in 288 evaluable women out of 399 who were exposed to tocilizumab shortly before or during pregnancy revealed no substantial increase in adverse pregnancy outcomes. However, this series was too small and diverse to demonstrate the safety of this agent in pregnancy (Hoeltzenbein et al).
  • Convalescent plasma and monoclonal antibodies: Pregnancy is not a contraindication to receiving convalescent plasma or current monoclonal antibodies, if otherwise meeting criteria.