Question

Covid 19 and Pregnancy Discussion

Answer 1

Answer:

Covid 19 and Pregnancy Discussion

Introduction:

Covid-19 is a viral infection that spreads through respiratory route.The disease has an incubation period of 5 to 14 days between the infection with the virus and the onset of symptoms, The infection manifests in adults and elderly with signs symptoms of fever , breathlessness,cough, chest pain and pneumonia. The children and young adults with the disease manifests as a multisystem inflammatory process with multiple systemic signs and symptoms.There is asymptomatic infection found in some people detected as a covid-19 positive on testing..Among the people who develop the disease symptoms , there is mild disease in in about 40% of the people and they can be managed at home With home isolation and medications,, moderate in another 40% needing hospitalization, severe in 15 percent who need iIntensive Care Management and respiratory support and very severe or critical in the remaining 5% Who need prolonged ventilatory support and have the highest mortality risk with covid-19.

The pregnant woman is equally vulnerable to the covid-19 as others and presents as a special consideration on account of her decreased immunity in pregnancy, decreased respiratory reserve on account of the normal physiology of pregnancy and the risk of increased respiratory complications for herself and also the risk of newborn covid-19 transmission

The pregnancy with covid-19 infection is discussed under various subheadings below with the standard clinical guidelines to be followed{ as recommended by WHO,ACOG } discussed in details.

Antenatal guidelines in pregnancy for covid-19

Antenatal precautions to prevent covid should be followed by all pregnant mothers visiting the health care centres for the routine checkups these include maintaining a safe distance between themselves and the others, use of mask ,use of general hygiene measures, for frequent hand washing ,staying away from people with infection, cough, cold and fever, avoiding unnecessarily visit to hospitals And crowded places.

Physiology in pregnancy and covid-19

There is a change in the body immunity status and disease fighting capability in pregnancy which decreases slightly as compared to the normal. As a result , pregnant women are at a little higher risk of contracting covid-19 as compared to others. Hence they should follow the precautions rigidly.

Also in pregnancy, there is decrease respiratory reserve on account of the pressure of the gravid uterus on the bases of the lung and poor lung expansion mainly associated with the later stages of pregnancy as the foetus grows.

There is a also a higher risk of severe disease in mothers with high risk pregnancies such as elderly mother, diabetic mothers hypertensive mothers. mothers with cancer or congenital heart disease or chronic respiratory diseases

The high risk Mothers with covid-19 infection tend to face more respiratory complications and preterm delivery.

Recommended information to be shared with pregnant mothers:

1. All standard hygiene precautions to be taken in order to prevent infection

2. There is a possibility of having asymptomatic covid-19 infection or mild infection with complete recovery and not every pregnancy with covid-19 will have a bad outcome and hence they should not be extremely anxious about covid-19 but be careful in self care measures and follow social distancing protocol

3. Tele health and tele consultation may be used to for some antenatal visits in order to decrease the the visits to the hospital thereby preventing cross infection.

The antenatal visits may be decreased then in usual times by the health care provider in the covid-19 conditions

4. General Health Care with nutritious diet, plenty of fluids, use of Folic acid in the first trimester, adequate rest, relaxation and exercise along with the required medications for the chronic diseases if present as prescribed

5.To attend regular antenatal visits and checkup as advised by the health care professionals.

Risk of covid-19 Transmission to foetus

There is no risk of covid-19 infection to the foetus through the placenta in utero or through the breast milk.

however there is a risk of transmission to newborn by direct respiratory droplets of the infected mother through contact with the mother during newborn handling and breastfeeding.

There is no evidence of the covid-19 transmission to foetus vertically and covid-19 has not been found in the amniotic fluid of the foetus or the vaginal secretions of an infected mother.

There is no risk of covid-19 being transmitted through breast milk as the virus has not been found in the breast milk of the affected mothers .

However the infection can transmit from the mother to the newborn true the respiratory droplets of the mother as and when the mother handles the newborn without precautions. hence the use of mask, proper hand hygiene by the mother and handling the newborn and temporary newborn isolation is advised if the mother is infected with covid-19 till she is cured of the infection.

Recommended isolation duration”

a] In asymptomatic covid 19 positive mother: at least ten days after the test Is positive or till the repeat testing is negative

b] for the symptomatic positive mother: At least two weeks from the onset of symptoms with the minimum period of 3 to 4 days without symptoms if or till the repeated testing RT_PCR is negative.

Management of covid-19 infection in pregnancy:

if the pregnant woman has exposure to covid-19 virus or has somebody in family with covid-19 or has symptoms suggestive of a covid-19 ,then clinical examination followed by RT_PCR covid 19 is done after obtaining nasopharyngeal and pharyngeal swab samples.

1.if the test is negative, the pregnant woman is monitored and watched for the development of symptoms.

2. if the test is positive and the is asymptomatic/mildly symptomatic, she is advised home isolation.The pregnant woman is monitored through regular telemonitoring/ telephonic methodology and is asked to keep account of the fetal kicks in order to monitor the fetal movements. In addition to the pregnant woman, self quarantine of the close contacts of the pregnant woman is recommended along with their testing.

She Is advised that is she should mandatorily report to the hospital in case of any deterioration of the symptoms for hospitalization and emergency treatment

An ultrasound to assess the fetal growth and fetal status is suggested 2 weeks after the mother is cleared of the acute infection and tests the negative for covid-19.

3. If the pregnant woman tests positive in the postpartum period, the mother is treated for the same with suitable antiviral drugs, immunomodulators and steroids as recommended by the hospital protocols and availability and the newborn is separated from the mother and the mother is isolated until the viral shedding clears and RT-PCR is negative.

4. if the pregnant woman test positive and is symptomatic with fever and respiratory complaints,cough,chest pain and shortness of breath and the pregnant woman should be admitted to the hospital in isolation room with negative pressure preferably.

The appropriate precautions and use of protective gear must be used by all the nursing and healthcare workers and clinical treatment done The fetal heart rate monitoring should be done in order to to assess for fetal viability and betamethasone injection should be given Minister to th pregnant woman if the pregnancy has crossed 28 weeks.

5. in case of severe illness needing ICU admission and ventilatory care, the pregnant woman is referred or transferred to the tertiary Hospital ICU facilities and respiratory care facilities

6. if the pregnant woman has visited the tertiary care Hospital

after 24 weeks of pregnancy,and the symptoms of covid-19 with severe needing ICU admission and ventilator care support then the seriousness of the condition must be explained to the family and the risk of preterm labour and prematurity must be explained to them

7.Precautions during delivery and newborn care

Early clamping of the umbilical cord and cleaning of the newborn

Monitoring of the newborn and testing of the newborn with RT PCR

. Breastfeeding can continue with the due precautions for using the breast milk expression as the virus is not excreted in the breast milk up but precautions must be followed to prevent the transmission of the virus from the mother to the newborn.

mother is isolated from the newborn if newborn tests RT- PCR test negative

8.The indications for termination of pregnancy are the Medical indications and obstretic indications of termination.

Maternal care in labour

1. The pregnant woman is given oxygen support in order to manage the oxygen saturation

2. continuous fetal head monitoring is advised in labour

3.Cesarean Section is not recommended unless indicated medically for other optical indications

4.Epidural analgesia is preferred in order to minimise the pain And prevent conversion to general anaesthesia. covid-19 is not a contraindication for spinal or epidural analgesia but precautions must be taken

5, Emergency Cesarean Section is done in case of deterioration in the mothe,r respiratory distress off the mother or other medical indications

6 Use of instrumental delivery can be done to augment the second stage of labour in order to decrease the maternal fatigue and hypoxia in case of slow progress per second stage of labour

ICU care for pregnant women with covid-19

1.Close monitoring withhourly observations is required in pregnancy in order to monitor the vital parameters, the blood pressure,Oxygen saturation and the fetal heart rate. and to pick up early determination

2. oxygen saturation must be closely monitored and if the oxygen saturation can fall suddenly due to the the viral infiltration of the lungs and hence oxygen supported with oxygen ventilatory standby should be kept available and ready.

3.The standard treatment advised is antiviral drugs with immunomodulators, use of corticosteroids and low molecular weight heparin as and when required as suggested by the physician

4.Abdominal shielding should be done in order to take the x ray chest and CT chest as necessary

5,Echocardiogram is advised in order to rule out viral myocarditis and ful sepsis screening is advised

6. if the WBC count is elevated secondary bacterial infection must be suspected and the patient should be started on antibiotics

7.Restriction of fluid boluses for fluid resuscitation: the fluid management should be done with

caution and patient should be given smaller bonuses and volumes of 250-500 ml at a time as there is a risk of overload in aggressive fluid resuscitation

8. The fetal heart rate monitoring should be continued at regular intervals

  Newborn Isolation techniques and breastfeeding protocol

fThe newborn born to a covid-19 mother should ideally be kept away from the mother there is a facility is available

In case of unavailability of facility the newborn should be kept at least distance of six feet from the mother Using a screen or a mask.

The mother should put on the mask ,perform hand hygiene and wash hands before feeding the newborn. She should be very careful while doing the breastfeeding

It is encouraged That the covid-19 mothers use of breast milk expression and breast pump in order to continue the breastfeeding with avoiding the risk of infection to the newborn

General precautions And guidelines for Health Care professionals dealing with pregnant women with Covid 19 infection.

1Use of personal protective equipment and standard precautions while examining the pregnant women.

2. Conducting the delivery Safely with proper precautions and providing quality postpartum care

3. performance of hand hygiene and washing the hands with soap and water before and after handling the patient and in between handling the patients

4. providing continuous and careful monitoring as there can be sudden development of hypoxia and decrease in the oxygenation of the pregnant women

5.To allay anxiety and provide continuous psychological support to the pregnant women maintaining the optimum level of their physical, psychologica,l mental and emotional health without bias,Roadies or negligence.

6.To counsel the pregnant woman and the patient's family about the probability of the complications that can occur as a result of covid-19 infection

7. to advise the patients with symptoms and high risk pregnancies For early hospitalization and institutional delivery

8. follow a multidisciplinary team based approach incorporating the various Specialists like obstetrics, infectious diseases, Pulmonary, Critical Care specialist paediatric Specialists and maternal-fetal medicine specialists and conduct the deliveries and the maternal care in tertiary hospitals equipped with all the facilities

9.Provide appropriate maternal and fetal monitoring and provide pharmacotherapy as per the protocol of the place

Statistical findings related to covid-19 and pregnancy

1. Hispanic black American women were found to be affected more by covid-19 infection in pregnancy and likely to suffer from severe disease than white American women.This issue needs to be addressed by providing adequate antenatal care, early screening and testing and access to quality healthcare for all populations

2. Higher incidence of complications due to covid-19 was noted in pregnant women with high age diabetes and hypertension and chronic diseases especially chronic respiratory diseases

3. There is an Increase in the riskof ICU admissions ,mechanical ventilation and death reported in symptomatic pregnant women as compared to the non pregnant women of the same age group confirming that pregnant women have a higher risk of complications

.The studies are ongoing to estimate the exact risk and percentages as a disease is an ongoing process..

Conclusion:

The covid-19 in pregnancy is associated with more complications and has a higher risk of ICU admission, ventilatory support, death in the pregnant women and is also associated with prematurity and fetal respiratory distress and death specially seen in high-risk pregnancies and certain racial groups like Black African and Hispanic women. This calls for improved care, early hospitalisation and aggressive management of the symptomatic pregnant women, high risk pregnant women with covid-19.