Coronavirus

COVID-19: pregnancy, delivery and breastfeeding - March 12th 2020

The Italian scientific community of neonatologists, paediatricians, gynaecologists, obstetricians and midwives (SIN, SIMP, SIP, ACP, SIGO, AOGOI, AGUI, SIAARTI and FNOPO) has joined the group established by Italian National Institute of Health (ISS) and coordinated by the National Centre for Disease Prevention and Health Promotion (CNaPPS). The main aim is to collect, assess and disseminate scientific literature updates on COVID-19 in pregnancy, childbirth and breastfeeding. The aim of the initiative is to provide indications for clinical practice intended for health professionals who take care of pregnancies, childbirth and breastfeeding/infant feeding in the Country. The plan is to disseminate each update through ISS’s Epidemiology website EpiCentro (https://www.epicentro.iss.it/), where on February 27 a document on the topic was published.

The CNaPPS has assumed responsibility to run daily a query against PubMed, Scopus, Embase, and CINAHL databases to search the most recent and accessible literature on the topic. No limits have been set for the study design or language of publication, while the start date has been fixed from January 2000 on. The results yielded from the search on Covid-19 in pregnant women, childbirth and puerperium have been put together with other documents from international governmental agencies, or scientific societies.

From the research carried out on the websites of the Ministries of Health and of the main Public Health Institutes of the countries affected by the pandemic, documents related to COVID-19 and pregnancy produced by various Scientific Societies and International Agencies have been found.

The Royal College of Obstetricians & Gynaecologists (RCOG) published a document for healthcare professionals on SARS-CoV-2 infection during pregnancy [1]. The document summarizes in a brief introduction the available evidence on the virus, the ways of maternal-fetal transmission and the effects of infection on mothers and newborns. Moreover, it contains information that can be offered to healthy pregnant women or those pregnant women with suspected or confirmed SARS-CoV- 2 infection; instructions for transportation, reception, hospitalization and care provision; and indications for healed women. The aim of the document is to improve emergency management, however, its information is contextualized to the United Kingdom reality, and may differ from what is applicable in Italy. The first chapter contains the indications that healthcare professionals can offer to pregnant women regarding the possibility of traveling, the concern of virus exposure, and the procedures for quarantine and for accessing the diagnostic test. The second chapter describes the indications for transportation, reception, hospitalization and care provision for pregnant women with suspected or confirmed SARS-CoV-2 infection. The different paragraphs systematically examine every possible maternal condition and/or care need. This descriptive effort represents a useful resource for anyone in Italy who needs to organize care provision for pregnant women with SARS-CoV-2 infection. The third chapter describes the indications on the care provision that should be offered to pregnant women healed from SARS-CoV-2 infection. The document ends with a flow-chart for the definition of the COVID-19 risk in women who address the obstetrics units, and with a bibliography on the available evidence.

From the literature review of the week we report the following updates.

One publication in The Lancet [2] describes a preliminary analysis of the clinical data of 15 pregnant women with COVID-19 between January 20 and February 10, 2020 in China. Of the 15 women examined, 11 delivered (1 vaginally and 10 through Caesarean Section) and 4 are still pregnant (3 in the second and 1 in the third trimester). The most common symptoms are fever (13/15) and cough (9/15). Two patients were asymptomatic and the most frequently associated laboratory parameters are lymphocytopenia (12/15) and increased PCR (10/15). All patients underwent a low-dose chest CT scan that allowed to diagnose mild pneumonia (no severe form or ARDS) and to follow its course through a semi quantitative score described by the authors. The benign course of the clinical situation was similar to that of non-pregnant women. Therapy involved nasal oxygen administration and empirical antibiotic treatment in addition to postpartum antiviral treatment. The four pregnant women were not treated with antiviral drugs and were equally healed. 14 of the 15 affected women tested negative after the therapy. With regard to perinatal outcomes, no newborn was positive for the virus, all had normal Apgar score and no cases of abortion, severe asphyxia or perinatal death were reported. The authors note that pregnancy and childbirth, contrary to what has been observed for H1N1 flu and SARS, do not seem to aggravate the symptomatic course or the clinical situation of viral pneumonia.

In Poon et al., the International Society of Ultrasound in Obstetrics & Gynecology (ISUOG) [3] published a policy document on the management of SARS – CoV 2 infection during pregnancy and puerperium. The authors present this document as a supplement to what already disseminated by the main international public health agencies. The paper explores the diagnostic, therapeutic and management aspects of infection in pregnancy, childbirth and after childbirth, suggesting offering care provision to pregnant women with confirmed COVID-19 infection in referral hospitals. Within the healthcare facilities, suspect/probable cases should be isolated and confirmed cases should be isolated in rooms with negative pressure ventilation systems, which have to be set up in the wards, in the labor/delivery block, and in intensive care. For the diagnosis of the condition, chest imaging, preferably through CT scan, is recommended for all pregnant women with suspected, probable or confirmed SARS – CoV 2 infection. There is no evidence of vertical transmission of the virus and the timing and mode of delivery such as the choice of general or regional anesthesia depend on the clinical condition of the woman, the gestational age and the fetal conditions. It is recommended multidisciplinary management that includes not only gynaecologists-obstetricians and maternal-fetal medicine specialists, but also midwives, anaesthesiologists, intensivists, virologists, microbiologists, neonatologists and infectious disease specialists.

Concerning the start and continuation of breastfeeding, several international agencies and groups are taking a position or maintaining the recommendations already issued. The CDC confirms that, currently, the virus has not been found in breast milk of women with COVID-19 [4]. WHO, in its document [5] (now also available in Italian) does not recommend mother-child separation and indicates that the mother can continue to breastfeed “considering the benefits of breastfeeding and the insignificant role of breast milk in the transmission of other respiratory viruses”. WHO, as well as UNICEF, recommends mothers to respect all the hygiene measures, including hand washing and the use of a mask when they are nearby the newborn [5,6]. The Royal College of Midwives, in a document intended for English midwives [7], reports the same indications.

The Academy of Breastfeeding Medicine, in a Statement of 10 March 2020, reiterates the points already supported by the International Agencies and reports indications on the home and hospital management of mothers with suspected or confirmed COVID-19 infection, symptomatic or asymptomatic. Whenever possible, rooming in should be maintained, complying with the safety instructions. The newborn should be directly breastfed or fed with expressed milk, if the clinical conditions or the maternal choice implies non-breastfeeding. Concerning hospital management, the ABM emphasizes that "the choice to breastfeed is the mother’s and the family" [8].

In the document for taking care of the mother with confirmed infection or waiting for the result, updated on March 9, 2020, the Collège National des Gynécologues et Obstétriciens Français indicates the case-by-case assessment of the possible separation of the mother-child dyad and breastfeeding modalities [9]. In the current uncertainty due to the scarce evidence available, the interim guidance developed by Poon et al., offers a summary of what has already been recommended by the main public health agencies and scientific societies. If the mother "is asymptomatic or mildly affected, breastfeeding and rooming in can be considered by the mother, in coordination with health care providers". In the case of mother critical clinical situation, “separation appears to be the best option, with attempts to express breastmilk in order to maintain milk production”. The authors do not specify the possible use of expressed breast milk or donated human milk [3].

As already reported in the comment of 5 March 2020 [10], some authors suggest to stop breastfeeding and to isolate temporary the newborn [11,12,13]. In light of the same limited evidence, which indicates how transmission through breast milk is unlikely, these indications seem to be based on a different application of the precautionary principle.

The documents produced and the evidence available on this topic are increasing. EpiCentro will continue with the updates as new information becomes available.

References:

1. Royal College of Obstetricians & Gynaecologists Coronavirus (COVID-19) Infection in Pregnancy – Information for healthcare professionals RCOG March 2020
2. Liu D, Li L, Wu X, Zheng D et al Pregnancy and perinatal outcomes of women with COVID-19 Pneumonia: a preliminary analysis. The Lancet-D-20-02737
3. Poon, L. C. (2020). ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals. https://doi.org/10.1002/uog.22013
4. CDC. Frequently Asked Questions and Answers: Coronavirus Disease 2019 (COVID-19) and Pregnancy. Page last reviewed: March 6, 2020
5. WHO. Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts. Retrieved March 11, 2020,
6. UNICEF, Coronavirus disease (COVID-19): What parents should know. How to protect yourself and your children. 
7. Royal College of Midwives. COVID-19 - Information for RCM Members.
8. Academy of Breastfeeding Medicine. ABM Statement on Coronavirus 2019 (COVID-19)
9. CNGOF. PRISE EN CHARGE AUX URGENCES MATERNITE D’UNE PATIENTE ENCEINTE SUSPECTEE Ou INFECTEE PAR LE CORONAVIRUS (COVID-19) – V1 (04/03/2020)
10. [9] Wang, L., Shi, Y., Xiao, T., Fu, J., Feng, X., Mu, D., … Zhou, W. (2020). Consensus. Chinese expert consensus on the perinatal and neonatal management for the prevention and control of the 2019 novel coronavirus infection (First edition) Ann Transl Med, 8(3), 47
11. Qiao, J. (2020). Comment What are the risks of COVID-19 infection in pregnant women?
12. Favre, G., Pomar, L., Qi, X., Nielsen-Saines, K., Musso, D., & Baud, D. (2020). Guidelines for pregnant women with suspected SARS-CoV-2 infection - Appendix. The Lancet Infectious Diseases, 0(0).