SMFM issues guidance on COVID-19, pregnancy

As the impact of the coronavirus (COVID-19) pandemic continues to escalate, the Society for Maternal-Fetal Medicine (SMFM) has released guidance on the maternal, fetal and neonatal implications of the disease. The guidance complements the Practice Advisory recently released by the American College of Obstetricians and Gynecologists (ACOG) and the evolving guidance from the Centers for Disease Control and Prevention (CDC).

Gestational impact
Information about the effect of COVID-19 on pregnancy is limited, but there have been several small reports which may offer insight into how the disease may impact gestation. SMFM cautions that the outcomes of these studies must be interpreted with caution due to their small numbers of participants.

• In two case studies on COVID-19 infection in pregnancy, totaling 18 women, only one suffered severe reparatory morbidity requiring intensive care unit admission and mechanical ventilation.

• Early data from a series of hospitalized nonpregnant patients in China found that up 32% of individuals developed severe pneumonia, and 19% of all infected hospitalized patients progressed to acute respiratory distress syndrome (ARDS). Mortality ranged from 1.4% to 4.3%, depending on region and testing strategies.

• A small study found no evidence of COVID-19 in the amniotic fluid or cord blood of six infants from infected women.

Risk of PTB
One question that has arisen is whether women infected with COVID-19 are at increased risk of preterm birth (PTB). Although a link may exist, it now appears that some cases were iatrogenic and not due to spontaneous PTB. It is not clear whether these outcomes were related to maternal infection. All of the infants in this single report were clinically well and no neonatal mortality was reported. When looking at other viral infections during pregnancy, such as influenza, PTB and low birth weight have occurred, though this is generally thought to be due to severe maternal illness.

Patient care
Women with acute illness should receive fetal management similar to the care provided to any critically ill woman. Continuous fetal monitoring in the setting of severe illness should only be considered with delivery when it would not compromise maternal health. At this point, very little is known about the natural history of pregnancy after a patient recovers from COVID-19.

Delivery timing
SMFM recommends that in most cases, timing of delivery not be dictated by maternal COVID-19 infection. In women who recover, the usual timing of pregnancy should not be altered. For women infected in the third trimester who recover, it may be reasonable to attempt to postpone delivery (if no other medical indications arise) until the mother tests negative for the disease or her quarantine status is lifted. The CDC recommends that facilities consider temporarily separating a woman with either confirmed COVID-19 or who is a patient under investigation (PUI) for the infection from her infant until she can no longer transmit the virus.

Breastfeeding
In regard to breastfeeding, a small study of nine infected women found no evidence of COVID-19 in breast milk. The CDC recommends that during temporary separation, women who intend to breastfeed should be encouraged to express their breast milk to establish and maintain milk supply. Before pumping, women should practice thorough hand hygiene and after pumping, all parts of the pump that come into contact with breast milk should be thoroughly washed, and the entire device should be disinfected according to the manufacturer’s instructions. Expressed breast milk should be given to the newborn by a health caregiver. For women and infants who are not separated, the CDC recommends that if a woman wishes to feed her infant at the breast, she should wear a facemask and practice hand hygiene before each feeding.

Travel
Because travel guidance from the CDC changes frequently, SMFM recommends that patients and providers check the CDC website frequently for guidance. Pregnant women with severe medical illnesses, such as heart, lung, or kidney disease, should follow the CDC precautions for those at higher risk and avoid crowds and keep space between themselves and others when out in public.

SMFM notes that because this is a rapidly changing situation, it is imperative for health care providers to monitor developments and make themselves aware of new information. The organization notes that it will continue to provide guidance as new data become available.

Look for a commentary on COVID-19 by Brenna L. Hughes, MD, and  Sarah K. Dotters-Katz, MD, in the Contemporary OB/GYN April isssue.