GUIDELINES IN THE MANAGEMENT OF PREGNANT PATIENTS WITH

SUSPECTED, PROBABLE OR CONFIRMED COVID-19 INFECTION

INTRODUCTION

The World Health Organization (WHO) has declared COVID-19 a global pandemic.
There are two official names being used. COVID-19 refers to the coronavirus disease
while Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) refers to the
virus itself.

The Department of Health (DOH) has recognized the pregnant population as a

“vulnerable” group. There are evidences showing that pregnant women are no more
likely to contract COVID-19 infection compared to the general population. However, a
small population of pregnant women may have altered body response to severe viral
infections resulting to a higher risk for severe illness, morbidity or mortality compared
with the general population.

OBJECTIVE

To provide guidelines for the obstetrician on the management of pregnant patients with
suspected, probable or confirmed COVID-19 infection.

GUIDELINES

1. The case definitions for COVID-19 in pregnant women are similar to that of the
general population namely: SUSPECTED case, PROBABLE case and CONFIRMED
case2.

2. Healthcare providers should wear appropriate PPE at all times2. Proper DONNING
and DOFFING of PPE should be observed2.

3. The possibility of COVID-19 infection should be suspected in a pregnant woman

with new-onset fever and/or respiratory symptoms as well as in pregnant woman with
severe lower respiratory tract illness without any clear cause3.

4. The gold standard to diagnose COVID-19 infections is Reverse

TranscriptionPolymerase Chain Reaction (RT-PCR) test3.

5. The Rapid Antibody-based tests (IgM/IgG) may be used as an adjunct to RT-PCR

test and should not be used as a stand-alonetest3.

6. All pregnant women with symptoms associated to COVID-19 infection should be

tested using RT-PCR test. Testing should also be considered in pregnant woman with
exposure to the disease such as those who lives in or had a history of travel within the
past 14 days to a place with community transmission or those who had close contact
with a suspected or confirmed case of COVID-193.

7. Asymptomatic individuals play a role in the transmission of COVID-19 infection.

Hence, it is prudent that all pregnant patientbe screened at 37-38 weeks age of
gestation using RT-PCR test. The pregnant woman should be instructed to go on leave
or work from home after the test and do self-quarantine until delivery. If labor ensues
>14 days from the last testing, repeat testing may be done3.

8. The use of radiologic imaging (CXR, chest CT and lung ultrasound) is not
recommended as a screening tool in asymptomatic or mild cases of COVID-19
infection in pregnant women. It is indicated in moderate to severe cases of the disease
and in cases with deterioration of respiratory function3.

9. Pregnant women with suspected, probable or confirmed COVID-19 infection who

are asymptomatic or recovering from an illness should have fetal growth and AFI
monitoring, with doppler of the umbilical artery (if necessary) every 2-4 weeks1.

10. Pregnant patient with confirmed COVID-19 infection acquired during the first or
early second trimester of pregnancy should have antepartum surveillance every month
including fetal growth assessment and a detailed anatomic scan at 18-24 weeks1.

11. Not all pregnant women with COVID-19 infection warrant hospital admission. Those
who are asymptomatic or those with mild disease and/or stable co-morbid illness may
be sent home for isolation with proper instructions. Those with severe disease and are
critically ill should be admitted and managed accordingly3.

12. A multidisciplinary team approach composed of an obstetrician, internist,

pulmonologist, infectious disease specialist and obstetric anesthetist is recommended
when managing severe case of COVID-19 in a pregnant woman3.

13. For scheduled Cesarean delivery or induction of labor in confirmed COVID

pregnant patient with mild or moderate symptoms not in need of immediate care,
planning the delivery prior to the peak (second week) of severity of the disease is
optimal2.

14. The decision to do induction of labor in pregnant patients with COVID-19 is

dependent on patient’s clinical presentation, presence of co-morbid illness/es, internal
examination findings (Bishop’s score) and hospital bed capacity. Since exposure time
between the patients and the healthcare providers are increased with induction of
labor, the risks and benefits should be weighed by the obstetrician when considering
this procedure3.

15. Minimize the number of healthcare providers involve in direct patient contact in any
obstetrical procedure. Minimize also changes in healthcare providers to limit
exposure2.

16. Pregnant women at 24-33 6/7 weeks age of gestation with suspected, probable or
confirmed COVID-19 who are at risk of preterm delivery within 7 days may benefit from
antenatal corticosteroids3.

17. For preterm cases requiring delivery, caution is advised regarding the use of
corticosteroids for fetal lung maturation if the mother with COVID-19 infection is
critically ill. Consultation with the multidisciplinary team is recommended2.

18. If a pregnant patient with COVID-19 infection goes into spontaneous preterm labor,
tocolysis should not be done in an attempt to delay delivery in order to complete the
dose of antenatal corticosteroids1.

19. Magnesium sulphate is used for neuroprotection in pregnancies of less than 32

weeks age of gestation and in those with hypertensive disorders complicating
pregnancy in order to prevent eclampsia. Since it has a potential for respiratory
complications, it should be used judiciously in pregnant patient with severe COVID-19
infection. It may be used as indicated in patients with mild/moderate symptoms2.

20. Early intervention with oxytocin and amniotomy is recommended to shorten the
time to delivery for pregnant women with suspected, probable or confirmed COVID-19
infection who are making a slow progress in the first stage of spontaneous labor2.

21. Oxygen inhalation via nasal cannula is not an aerosolizing procedure but the
equipment is in contact with the maternal respiratory tract secretions which may result
to a higher risk of contamination/exposure between the patient and healthcare provider
(especially in asymptomatic carriers). Because of the risk of transmission of COVID-19
infection and lack of fetal benefit from intrapartum oxygen (based on studies), the use
of oxygen for fetal resuscitation is not recommended2.

22. COVID-19 infection alone is not an indication for Cesarean delivery. Mode of
delivery depends on obstetrical indications3.

Cont...

23. COVID-19 infection alone is not an indication for pregnancy termination and
decisions regarding delivery timing should be individualized. If a pregnant COVID-19
patient can be successfully treated, pregnancy should be allowed to continue until
term. However, if the pregnant woman clinical condition is deteriorating and may lead
to intrauterine fetal demise or loss of both mother and infant, early delivery may be
warranted3.

24. The decision whether or not to perform Essential Intrapartum Newborn Care (EINC)
should be done on a case to case basis3. Delayed cord clamping regardless of
COVID-19 status may still be done2.

25. Neuraxial Anesthesia (Epidural, Spinal or Caudal) is preferred. Inhalational or

General Anesthesia should be avoided in pregnant women with COVID-19 infection
during delivery3.

26. It is still unclear whether there is vertical transmission from mother to fetus, but
limited cases have shown no evidence of vertical transmission of COVID-19 during the
last trimester of pregnancy. (No studies done during first and second trimester)3.

27. The patient and her family should be informed on the risk of viral transmission to
the infant during breastfeeding. They should be advised on the numerous benefits of
breastfeeding. The decision whether or not to breastfeed ultimately depends on the
patient and her family3.

28. Use of NSAID’s for pain relief in woman suspected or positive for COVID-19 is best
avoided and replaced with safer alternatives2.

29. To limit the risk of infection transmission, all vaginal deliveries should be discharge
on day 1 postpartum or even same day if possible. All Cesarean deliveries should be
discharge on second postoperative day or first operative day if all the milestones have
been met2.

30. Visitation should be limited to one person only from admission until discharge2.

31. Postpartum visits may be through “telemedicine” if possible2.

REFERENCES:

1. Philippine Society of Maternal Fetal Medicine “COVID-19 and Pregnancy: A Guide to

Maternal Fetal Medicine Specialists and General Obstetric Practitioner”

2. Philippine Society of Maternal Fetal Medicine “COVID-19 and Pregnancy: Interim

Guidelines on Labor and Delivery for Maternal Fetal Medicine Specialists and General
Obstetric Practitioners”

3. The PIDSOG Handbook: A Guidance for Clinicians on the Obstetric Management of

Patients with Coronavirus Disease 2019 (COVID-19); April 2020

23. COVID-19 infection alone is not an indication for pregnancy termination and
decisions regarding delivery timing should be individualized. If a pregnant COVID-19
patient can be successfully treated, pregnancy should be allowed to continue until
term. However, if the pregnant woman clinical condition is deteriorating and may lead
to intrauterine fetal demise or loss of both mother and infant, early delivery may be
warranted3.

24. The decision whether or not to perform Essential Intrapartum Newborn Care (EINC)
should be done on a case to case basis3. Delayed cord clamping regardless of
COVID-19 status may still be done2.

25. Neuraxial Anesthesia (Epidural, Spinal or Caudal) is preferred. Inhalational or

General Anesthesia should be avoided in pregnant women with COVID-19 infection
during delivery3.

26. It is still unclear whether there is vertical transmission from mother to fetus, but
limited cases have shown no evidence of vertical transmission of COVID-19 during the
last trimester of pregnancy. (No studies done during first and second trimester)3.

27. The patient and her family should be informed on the risk of viral transmission to
the infant during breastfeeding. They should be advised on the numerous benefits of
breastfeeding. The decision whether or not to breastfeed ultimately depends on the
patient and her family3.

28. Use of NSAID’s for pain relief in woman suspected or positive for COVID-19 is best
avoided and replaced with safer alternatives2.

29. To limit the risk of infection transmission, all vaginal deliveries should be discharge
on day 1 postpartum or even same day if possible. All Cesarean deliveries should be
discharge on second postoperative day or first operative day if all the milestones have
been met2.

30. Visitation should be limited to one person only from admission until discharge2.

31. Postpartum visits may be through “telemedicine” if possible2.

REFERENCES:

1. Philippine Society of Maternal Fetal Medicine “COVID-19 and Pregnancy: A Guide to

Maternal Fetal Medicine Specialists and General Obstetric Practitioner”

2. Philippine Society of Maternal Fetal Medicine “COVID-19 and Pregnancy: Interim

Guidelines on Labor and Delivery for Maternal Fetal Medicine Specialists and General
Obstetric Practitioners”

3. The PIDSOG Handbook: A Guidance for Clinicians on the Obstetric Management of

Patients with Coronavirus Disease 2019 (COVID-19); April 2020