COVID-19 Intelligence Report: OB/GYN

Updates on obstetric complications: 

• A systematic review identified 13 papers including 538 pregnancies complicated by COVID-19. The reported rates of maternal critical illness was low (1.4%; no mortalities), preterm birth rate was 20%, C-section rate was 85%, vertical transmission rate was 0%, and neonatal death rate was 0.3%. 

Title: Placental Pathology in COVID-19

Publisher: American Journal of Clinical Pathology

Publication Date: May 22, 2020

URL: https://academic.oup.com/ajcp/advance-article/doi/10.1093/ajcp/aqaa089/5842018

Key Takeaway: Sixteen placentas from patients with severe acute respiratory syndrome from COVID-19 were examined (15 with live birth in the third trimester, 1 delivered in the second trimester after intrauterine fetal demise). Relative to controls, COVID-19 placentas show increased prevalence of decidual arteriopathy and other features of MVM, a pattern of placental injury reflecting abnormalities in oxygenation within the intervillous space associated with adverse perinatal outcomes. Only 1 COVID-19 patient was hypertensive despite the association of MVM with hypertensive disorders & preeclampsia. Changes may reflect a systemic inflammatory or hypercoagulable state influencing placental physiology.

       Title: Clinical Implications of Universal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Testing in Pregnancy

Publisher: Obstetrics & Gynecology

Publication Date: May 19, 2020

URL: https://journals.lww.com/greenjournal/Citation/9000/Clinical_Implications_of_Universal_Severe_Acute.97343.aspx

Key Takeaway:  Pregnant women with SARS-CoV-2 infection on admission do not seem to be reliably identified using symptom screening alone.  Observed SARS-CoV-2 infection prevalence identified with universal screening (3.6%, 95% CI 2.3–5.4%) is sixfold higher than prevalence rates based on reported rates for our county (0.6%) during this period.

Title: Interim Guidance on Breastfeeding and Breast Milk Feeds in the Context of COVID-19, CDC 

Publication Date: April 28, 2020

URL: https://www.cdc.gov/coronavirus/2019-ncov/hcp/care-for-breastfeeding-women.html     

Key Takeaway: No definitive data if COVID is spread through breast milk

• “We do not know whether mothers with COVID-19 can transmit the virus via breast milk, but the limited data available suggest this is not likely to be a source of transmission.”
• If mother is positive, consider baby positive, and quarantine for 14 days.

Title: Obstetric Anesthesia During the COVID-19 Pandemic 

Publisher: Anesthesia & Analgesia

Publication Date: April 6, 2020

URL: https://journals.lww.com/anesthesia-analgesia/Abstract/publishahead/Obstetric_Anesthesia_During_the_COVID_19_Pandemic.95696.aspx  

Key Takeaway:  Anesthetic recommendations for COVID patients on L&D.

Title:  Outpatient Assessment and Management for Pregnant Women with Suspected or

Confirmed Novel Coronavirus (COVID-19)

Publisher: Society for Maternal-Fetal Medicine

Publication: April 22, 2020   

URL: https://www.smfm.org/covidclinical 

Key Takeaway: 

The Society for Maternal-Fetal Medicine (SMFM) and the American College of Obstetricians and Gynecologists (ACOG) have developed an algorithm for assessment and management of pregnant women with COVID-19 (available in English and Spanish). 

• SMFM and the Society for Obstetric Anesthesia and Perinatology (SOAP) continue to revise and update their guidance on Labor and Delivery COVID-19 Considerations. 
• In their previously released statement, SMFM and ACOG state that while the CDC currently “does not indicate that pregnancy alone puts people at higher risk for severe illness resulting from COVID-19 infection,” the evidence underlying this statement is limited and will be augmented over time by additional data and testing. 

Title:  Clinical Characteristics of Pregnant Women with COVID-19 in Wuhan China,

NEJM, April 17, 2020

Publisher: New England Journal of Medicine

Publication: April 17, 2020   

URL: https://www.nejm.org/doi/full/10.1056/NEJMc2009226

Key Takeaway: 

● On this review of pregnant women treated for COVID-19 in December 2019-March 2020 in Wuhan, the risk of severe disease appeared to be similar to that in the general population. Nine of 118 patients had severe disease and only one required ventilation.  

Title: Universal Screening for SARS-CoV-2 in Women Admitted for Delivery

Publication:  New England Journal of Medicine, April 13, 2020

URL: https://www.nejm.org/doi/full/10.1056/NEJMc2009316

Key Takeaway: This letter reports the experience of 215 pregnant women who delivered infants at the New York–Presbyterian Allen Hospital and Columbia University Irving Medical Center.  87.9% of SARS-CoV2 positive women were asymptomatic at presentation.  Four women (1.9%) had fever or other symptoms of Covid-19 on admission, and all 4 women tested positive for SARS-CoV-2 (Figure 1). Of the 211 women without symptoms, all were afebrile on admission. Nasopharyngeal swabs were obtained from 210 of the 211 women (99.5%) who did not have symptoms of Covid-19; of these women, 29 (13.7%) were positive for SARS-CoV-2. Thus, 29 of the 33 patients who were positive for SARS-CoV-2 at admission (87.9%) had no symptoms of Covid-19 at presentation.

Title: Joint Statement: Recent Developments Regarding COVID-19 and Pregnant Women

Publication: American College of Obstetricians and Gynecologists, April 6, 2020

URL: https://www.acog.org/-/media/project/acog/acogorg/files/advocacy/letters/joint-statement-recent-developments-regarding-covid-19-and-pregnant-women.pdf

Key Takeaway: ACOG and SMFM statement regarding CDC’s removal of pregnant women from the list of those at higher risk of COVID-19 severe illness; recommend precautions to minimize exposure.

Title: Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings

Web Address: https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html

Key Takeaway: This is an April 4, 2020 update of CDC Guidance related to:

• Visitors and essential support persons to pregnant women who have known or suspected COVID-19 infection
• Prioritized testing of pregnant women with suspected COVID-19 at admission or who develop symptoms of COVID-19 during admission
• Testing of infants with suspected COVID-19 and isolation from other healthy infants
• Determination of whether to keep a mother with known or suspected COVID-19 and her infant together or separated after birth on a case-by-case basis

PRIORITY (Pregnancy Coronavirus Outcomes Registry)

• https://priority.ucsf.edu/ 
• PRIORITY (Pregnancy CoRonavIrus Outcomes RegIsTrY) is a nationwide study of pregnant or recently pregnant women who are either under investigation for Coronavirus infection (COVID-19) or have been confirmed to have COVID-19, designed to help patients and doctors better understand how COVID-19 impacts pregnant women and their newborns. If you have a pregnant patient, please register them at this website.

WHO-China Joint Mission on COVID-19 Report

• https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf 
• Preliminary data of 147 pregnant women (64 confirmed, 82 suspected and 1 asymptomatic) suggest pregnant women are not at higher risk of severe disease; however, the number of women is too small to change the recommendation that women be considered higher risk (page 32).  February 2020

Coronavirus (COVID-19) Infection in Pregnancy

• https://www.rcog.org.uk/globalassets/documents/guidelines/2020-03-21-covid19-pregnancy-guidance-2118.pdf  
• Guidelines from the Royal College of Obstetricians and Gynaecologists (UK)  
• Note from submitter: Guidelines from the Royal College of Obstetricians and Gynaecologists (UK) released March 21, 2020.

COVID-19 in Pregnancy: Early Lessons

• https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/ymob/COVID_Early_Lessons_032620-1585251897613.pdf
• Note from submitter: 2 of 7 confirmed COVID-19-positive pregnant patients in this series were asymptomatic upon admission, exposing multiple health care workers; therefore, changes to obstetrical practices may be indicated to protect HCWs. Released March 26, 2020.

Labor and Delivery                                                              

• https://youtu.be/fT5h4oMUOFk
• COVID-19 Preparing a Labor and Delivery Unit  
• Note from submitter: Society for Maternal Fetal Medicine guidelines for preparation of Labor and Delivery units.