Coronavirus

COVID-19: pregnancy, delivery and breastfeeding - April 16th 2020

As part of the increasingly current debate on whether or not to offer a swab to asymptomatic subjects, two contributions were published this week that offer new opportunities for reflection [1,2].

Between March 22 and April 4, 2020, at the Allen Hospital in New York and the Columbia University Irving Medical Center, 210 asymptomatic women and 4 symptomatic women with COVID-19 infection gave birth. All women underwent nasopharyngeal swab screening for SARS-CoV-2 virus at admission. Beyond the symptomatic women, 13.7% of the asymptomatic tested positive. The fact that a significant proportion of maternal infections may be asymptomatic makes it difficult to estimate the real prevalence of the condition and compromises the possibility of guaranteeing protected pathways within health services for both healthcare professionals and mothers and babies [1].

An article by Ferrazzi et al. [2] describes the work undertaken by the task force set up in the Lombardy Region on February 24, 2020 with the aim of producing recommendations for obstetric practice related to the management of the COVID-19 emergency. The task force identified 6 reference Hub hospitals intending to centralize the patients and concentrate human resources, multidisciplinary skills and needed PPE. The work describes care protocols and procedures and the preliminary analysis of the first 42 cases of COVID-19 positive pregnant women in Lombardy. The report also reports an interesting reflection on the problem of asymptomatic and SARS-CoV-2 positive women, suggesting that for a combined effect of gender, young age and immune status of pregnancy, in areas with a high prevalence of infection there is a greater frequency of positive but asymptomatic women.

Studies on vertical transmission of infection continue to be published.

Wang [3] describes, in a complete and detailed way, the available and unavailable evidence on the vertical transmission of the SARS-CoV-2 infection in pregnancy, confirming that, to date, it has not yet been demonstrated.

A letter, written by fetal therapy specialists [4], deal with the risk of vertical maternal-fetal transmission of COVID-19 infection in the event of invasive procedures involving transplacental access that could increase the risk of intra-amniotic bleeding, compromising the fetal-maternal barrier.

A work [5] proposes a classification system that includes 5 mutually exclusive classes to define the probability of infection, which is distinguished into: certain, probable, possible, improbable, and absent. For each class the diagnostic tests and the interpretative criteria of their answers are defined. Related to the case definition, the authors propose to replace the generic terminology "vertical or horizontal transmission of the infection" with: "congenital infection in intrauterine death/stillbirth", "congenital infection in live born", "neonatal infection acquired intrapartum", "neonatal infection acquired postnatally". The fact that a significant part of maternal and neonatal infections is asymptomatic makes it difficult to evaluate the real impact of the condition on newborns and, at the same time, compromises the possibility to adequately protect the health professionals.

Chinese authors [6] present a series of 17 positive COVID-19 women who gave birth. The gestational age is between 35 and 41 weeks and the deliveries occurred between 1 and 26 days from the beginning of the SARS-CoV-2 symptoms. Five infants developed pneumonia and two swabs collected within 24 hours of delivery tested positive. The authors conclude that they cannot confirm the vertical transmission due to the unavailability of the virus detection in the cord blood, amniotic fluid or placenta.

A series of articles summarize the evidence available in the literature on COVID-19 during pregnancy, also through narrative reviews. Parazzini et al. present a narrative review of 13 studies that describes the data available on the modality of delivery, the vertical/peripartum transmission of the infection and the neonatal outcomes in pregnant SARS-CoV-2 positive women [7]. The authors review the available information related to pregnant women during MERS, SARS and new Coronavirus epidemics and summarize the main maternal and perinatal outcome indicators in a synoptic table to facilitate a comparative analysis that confirms the lower severity of the SARS-CoV-2 infection compared to the previous ones [8]. Bauer et al. present recommendations based on evidence or expert opinion addressed to anesthesiologists caring for women during the COVID-19 pandemic with a focus on good practices [9].

The following articles regard different care aspects related to obstetric topics in the context of the SARS-CoV-2 pandemic. An article [10] discusses the emotional, mental and physical support that must be guaranteed to healthcare professionals attending the birth during the COVID-19 pandemic. To prevent stress and burnout of healthcare professionals, adequate work planning, availability of appropriate PPE, emotional and psychological support, as well as adequate nutrition, rest and physical activity are recommended. Another paper [11] examines the appropriate risk-benefit assessments that must be adopted in clinical practice to decide if and when to use corticosteroids for the treatment of prematurity in COVID-19 positive women. A group of obstetricians from the University of Ohio presents a proposal for an operative protocol to perform caesarean section in women with suspected or confirmed COVID-19 infection [12].

Chandrasekharan et al. [13] present a review of the possible options to be discussed with parents in a shared decision-making process relating to childbirth and newborn care in situations of suspected or confirmed mother COVID-19.

About breastfeeding, no new evidence emerges from the various published studies on vertical transmission through breast milk [14,7,3,15,16].

Different indications remain on mother-child contact after birth, rooming in, and breastfeeding in suspected or confirmed mothers COVID-19. The Chinese National Obstetrics and Medical Quality Management and Control Center suggests immediate and prolonged mother-baby separation for at least 14 days and not breastfeeding [17]. Otherwise, the April, 7 update of the British Royal Colleges [18] support the previous indications on the promotion of the mother-child relationship and breastfeeding, as well as the World Health Organization in the document of March, 13 [19]. In the April, 4 update [20] of the "Considerations for Inpatient Obstetric Healthcare Settings", the US CDC reviews some of its indications. It is recommended the presence of a single support person without acute respiratory symptoms chosen by the woman; alternative ways of interaction are suggested for visitors, such as video calls. All people entering the healthcare facilities must be equipped with a mask. The decision to separate the suspected or confirmed COVID-19 mother from her newborn after birth should be made on a case by case assessment, through a decision-making process shared between the mother and the team. Elements to consider include: clinical conditions of the mother and the child; test result of the mother (confirmed vs suspected) and the child (if the newborn is positive, the need for separation declines); mother's desire to breastfeed; logistic possibility of the facility to implement the separation or colocation; possibility of continuing the separation after discharge; other risks and benefits of temporary separation. In the event that the separation does not occurred, the indications for the risk transmission reduction persist, always in a decision-making process shared with the mother.

Stuebe [21] reviews the potential consequences of mother-infant separation. Among these:

• the separation may not prevent infection once the newborn has returned home with his mother, as social distancing is not always possible or feasible at home and other family members may be infected;
• the interruption of skin-to-skin contact at birth disrupts the newborn physiology, increasing the stressors with negative effects on the disease course;
• the separation is a stressor for the mother; studies have shown the positive effects of mother-baby contact also on the mother. Separation increases stress levels and can worsen the clinical course;
• the separation interferes with the breast milk provision, disrupting innate and specific immune protection;
• the early separation disrutps breastfeeding, and not breastfeeding increases the risk of infant hospitalization for pneumonia;
• the separate isolation of mother and child doubles the burden on the health system.

Among the regional documents, the Task Force of the Lombardy Region indicates the presence of the partner during labor and delivery, but not in the postpartum area. It also recommends that all breastfeeding women should wear the surgical mask; COVID-19 positive asymptomatic or with moderate symptoms mothers can breastfeed, positive and symptomatic mothers, instead, must be separated from their newborns and can express their milk for their infants [2].

The document produced by the technical-scientific advisory commission on the birth path of the Emilia Romagna Region indicates the presence of a single companion. In the case of symptomatic women in stable conditions, mother and newborn must be kept together in an isolated room. The mother must use the mask and can breastfeed, according to the mother's desire, and the hygiene measures. The document also refers to the planning of the discharge, arranging post-discharge checks with the territorial services and with the paediatrician [22].

References

1. Sutton, D., Fuchs, K., D’Alton, M. & Goffman, D. Universal Screening for SARS-CoV-2 in Women Admitted for Delivery. N. Engl. J. Med. 1–2 (2020). doi:10.1056/NEJMc2009316
2. Ferrazzi, E. M. et al. COVID-19 Obstetrics Task Force, Lombardy, Italy: executive management summary and short report of outcome. Int. J. Gynaecol. Obstet. (2020). doi:10.1002/ijgo.13162
3. Wang, C., Zhou, Y., Yang, H. & Poon, L. Intrauterine vertical transmission of SARS-CoV-2: what we know so far Chen. (2020).
4. Deprest, J. et al. Feto-placental surgeries during the covid-19 pandemic: starting the discussion. (2020).
5. Shah, S., Diambomba, Y., Acharya, G., Shaun, K. & Bitnun, A. Classification system and case definition for SARS-CoV-2 infection in pregnant women, fetuses, and neonates. (2020).
6. Khan, S. et al. Association of COVID-19 infection with pregnancy outcomes in healthcare workers and general women. (2020). doi:10.1016/j.cmi.2020.03.034
7. Parazzini, F. et al. Delivery in pregnant women infected with SARS-CoV-2: A fast review. Int. J. Gynaecol. Obstet. (2020). doi:10.1002/ijgo.13166
8. Saccone, G., Carbone, F. & Zullo, F. The Novel Coronavirus (2019-nCoV) in pregnancy: what we need to know. Eur. J. Obstet. Gynecol. Reprod. Biol. (2020). doi:10.1016/j.ejogrb.2020.04.006
9. Bauer, M. et al. Obstetric Anesthesia During the COVID-19 Pandemic. Anesth. Analg. 1 (2020). doi:10.1213/ANE.0000000000004856
10. Wilson, A. N. et al. Caring for the carers: Ensuring the provision of quality maternity care during a global pandemic. Women and Birth (2020). doi:https://doi.org/10.1016/j.wombi.2020.03.011
11. Mcintosh, J. J. Corticosteroid Guidance for Pregnancy during COVID-19 Pandemic. Am J Perinatol 2019, 1–4 (2020).
12. Gonzalez-Brown, V. M., Reno, J., Fiorini, K., Costantine, M. M. & Lortz, H. Operating Room Guide for Con fi rmed or Suspected COVID-19 Pregnant Patients Requiring Cesarean Delivery. Am J Perinatol 43210, (2020).
13. Chandrasekharan, P. et al. Neonatal Resuscitation and Postresuscitation Care of Infants Born to Mothers with Suspected or Confirmed SARS-CoV-2 Infection. Am. J. Perinatol. 14203, (2020).
14. Mimouni, F. et al. Perinatal aspects on the covid-19 pandemic: a practical resource for perinatal – neonatal specialists. (2020). doi:10.1038/s41372-020-0665-6
15. Chen, Q. et al. Vaginal Delivery Report of a Healthy Neonate Born to a Convalescent Mother with COVID-19. 0–3 doi:10.1002/jmv.25857
16. Zaigham, M. & Andersson, O. Maternal and Perinatal Outcomes with COVID-19: a systematic review of 108 pregnancies. Acta Obstet. Gynecol. Scand. 0–3 (2020). doi:10.1111/aogs.13867
17. National Obstetrics and Medical Quality Management and Control Center. New coronavirus pneumonia maternal delivery management recommendations. (2020).
18. Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Paediatrics and Child Helath & Obstetric Anaesthetists’ Association. Coronavirus (COVID-19) Infection in Pregnancy. 1–54 (2020).
19. World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. Who 2019, 12 (2020).
20. CDC. https://www.cdc.gov/....
21. Stuebe, A. Should Infants Be Separated from Mothers with COVID-19? First, Do No Harm. Breastfeed. Medi 15, 1–2 (2020).
22. Commissione consultiva tecnico-scientifica sul percorso nascita. Nuovo coronavirus SARS-CoV-2 Indicazioni per le professioniste e i professionisti del percorso nascita della regione Emilia-Romagna. (2020).