Overview of Pandemic Pregnancy: COVID-19 Edition

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which causes the coronavirus disease 2019 (COVID-19) was first identified in Wuhan, China on December 2019. (1)  On 11 March 2020, approximately 3 months after its identification, World Health Organization (WHO) declared the disease to be a pandemic, owing to the rapid spread of the infection across the globe. (2)

In an effort to curb further spread of COVID-19, many countries launched robust national response which included but is not limited to mandatory curfews, quarantines, lockdowns, heightened surveillance, closure of non-essential public services, private businesses and educational institutes as well as closure or strict control of land and air borders.(3,4,5) These moves are largely necessary and justified as they help to prevent massive outbreaks which might then put a strain on the limited healthcare resources available. However, they undoubtedly have their own repercussions, one of which is the restricted access to healthcare providers for non-emergency cases. Moreover, one of the biggest challenges faced by many countries when it comes to tackling COVID-19 pandemic is the struggle to strike the optimal balance between attending to COVID-19 cases while maintaining other essential health services.(6) This includes sexual and reproductive health services which comprised of pregnancy, childbirth, contraception and family planning, among others.

Pregnancy is often perceived to be life-changing and a unique experience for many parents and families, both physically and emotionally. This holds true even under ‘normal’ circumstances. Naturally, bringing a pandemic into the equation, together with the host of changes that comes with it, would have a profound impact on the entire experience for most mothers and their families. In terms of direct health-related consequences, one of the most notable one would be the increased risk in adverse outcomes or severe illness among pregnant women as compared to non-pregnant people.(7) However, if we look at the broader picture, pregnant women may also be impacted by limited access to maternity and reproductive health services due to travel restrictions as well as shortage of manpower and infrastructures to cater for these services.

Preventive Measures

In view of the heightened risk faced by pregnant women due to COVID-19 infection, prevention remains as one of the best ways to mitigate the risk. The recommendations are largely similar to those for non-pregnant people which include physical distancing of at least two metres, avoiding crowded and confined spaces, using face masks or multilayer cloth face covering, as well as frequent sanitisation and disinfection measures.(8) However, specific attention should be given to pregnant mothers with children under 10 years of age in the household, as COVID-19 infection among children of this age group may be mild or asymptomatic. The absence of symptoms does not negate the possibility of transmission during incubation period, hence some recommendations to tackle this include monitoring the children’s playtime with other children from different households and taking necessary precautions when in-person meetings or interactions between children happen. (9)

In terms of vaccination, definitive recommendations could not be produced due to the exclusion of pregnant or lactating women from the numerous vaccine trials that are being conducted presently. However, based on the general understanding about the mechanism of action behind mRNA vaccines, experts are of the opinion that they are unlikely to result in adverse foetal, newborn nor maternal effects among pregnant people and breastfeeding newborns. Hence the general opinion is to not withhold the vaccines on the basis of pregnancy or lactation alone, especially if the patient is eligible and desires vaccination. Instead, appropriate counselling should be offered to patients to discuss current knowledge and evidence available, thereby allowing patients to make more informed decisions.(10,11,12)

Clinical Course and Implications

While the risk of acquiring COVID-19 infection is not increased due to pregnancy, the clinical course of infection appears to be worse in pregnant women, whereby there is a higher chance of hospitalisation, rapid deterioration, Intensive Care Unit (ICU) admission and even death. Older women and those with co-morbidities are particularly at risk.(13,14) Common complications that have been reported include pneumonia, respiratory failure, acute respiratory distress syndrome (ARDS), thromboembolic complications, secondary infections, disorders of smell and taste, acute kidney failure and psychiatric illness, among others. However, on a positive note, more than 90% of infected patients do recover without requiring hospitalisations. The median time taken for symptoms to resolve is 37 days, as reported by an ongoing nationwide prospective study conducted in the United States.(15)

As for vertical transmission, the extent to which it occurs remains largely unclear. Probable vertical transmission has been reported in some cases. However, most of them occurred in the setting of third trimester maternal infection within 14 days of delivery. On the other hand, a systematic review on current available evidence illustrated that the risk of vertical transmission for SARS-CoV-2 is low. Nevertheless, the infection may lead to profound impact and complications among newborns, thus necessitating continuous clinical monitoring and preventive measures to protect them from horizontal transmission.(16)

Management Strategies

Care for pregnant women who have been infected with SARS-CoV-2 may be stratified according to their symptom status. For instance, treatment for asymptomatic patients largely involve risk assessment, close monitoring, necessary infection control steps and self-isolation. On the other hand, symptomatic patients would require more thorough assessment and clinical care which is largely influenced by the presence of any underlying medical issues or obstetric complications, severity of the symptoms, as well as patients’ social background. A large percentage of these patients can be assigned to homecare, provided they do not have other risk factors which may lead to sudden, rapid deterioration.(17) Close monitoring and follow-up with these patients is imperative to prevent adverse outcomes.(18)

In contrast, patients requiring inpatient care are predominantly those with underlying conditions which warrant admission, moderate to severe signs and symptoms, at risk for cytokine storm syndrome (fever >39⁰C after using acetaminophen) and those with critical disease. (18) In severe cases, adequate maternal respiratory support is vital, due to heightened risk of profound acute hypoxemic respiratory failure from ARDS. It is also recommended to maintain the peripheral oxygen saturation (SpO2) at ≥95% for pregnant women. Prophylactic-dose anticoagulation can be provided as long as there is no contraindication to its use and some choices include unfractionated heparin and low molecular weight heparin (LMWH). Use of glucocorticoids may also be warranted, with the more common choice being dexamethasone. However, administration should also take into account whether the timing and other criteria to induce foetal maturity is fulfilled, as this also requires use of dexamethasone. In addressing COVID-19 infection alone (without the need to induce foetal maturity), reasonable alternatives to dexamethasone include methylprednisolone or hydrocortisone, although the efficacy in terms of decreasing maternal mortality is not as clear.(19) As for antipyretic and analgesic effects, acetaminophen remains as the preferred agent. The necessity for foetal monitoring is determined based on gestational age, maternal vital signs and presence of comorbidities.(20)

Conclusion

In most cases, pregnant women with preterm infection and non-severe illness without any other complications or indications would not require prompt delivery. Ideally the delivery will occur at a later period after a negative testing result is obtained, thus reducing the possibility of post-natal transmission to the new-born. Early delivery may be beneficial if the mother is severely ill with COVID-19 pneumonia and has reached at least 32 weeks gestation.(21,22) Regardless of the clinical profile, it is important to acknowledge that the entire process may cause significant distress to these mothers and their families, especially in light of the other restrictions and limitations caused by the pandemic. Therefore, adequate measures should be taken to attend to both physical and emotional well-being of these patients.

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