Coronavirus

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

On March 18, 2020, the Royal College of Obstetricians Gynaecologists, in collaboration with the Royal College of Midwives, Royal College of Paediatrics and Child Health, Public Health England and Health Protection Scotland, published the third update of the document on Coronavirus infection (COVID-19) and pregnancy [1].

The main updates are related to the recommendation to test for SARS-CoV all women who, at the time of hospital admission for delivery, have symptoms that indicate COVID-19 and to consider all symptomatic women as potentially infected. The clusters and co-infections evidence within some households has also promoted the request for preventive measures, such as frequent hand washing and masks use, for asymptomatic partners who wish to access the obstetrics unit in order to attend the birth. The positive partners are categorically excluded and must comply with the indication of isolation.

The Royal Colleges recommend that when the pregnant woman is hospitalized for worsening symptoms and suspected/confirmed COVID-19 infection, a multidisciplinary assessment meeting should be held as soon as possible, involving - ideally - an infectious disease specialist, an obstetrician-gynaecologist, a midwife and an anaesthesiologist responsible for obstetric care. Discussion and conclusions should be discussed with the woman, including: care priorities, the most appropriate place of care (e.g. intensive care, isolation room in the infectious disease ward or other isolation rooms) and the specialists involved, the team's concerns about specific considerations in pregnancy, especially the baby condition.

With regard to the delivery, in the case of maternal symptoms that indicate a suspected or certain infection, the update of the RCOG recommends, whenever possible, to postpone the caesarean sections and the planned inductions in order to reduce the risk of infection transmission within the Hospital.

Another update relates to the recommendation to avoid water birth for women with SARS-CoV-2 infection because of the evidence of faecal transmission of the virus. Worthy of attention is a new statement on the importance of using the chest CT scan that is considered a necessary examination in the assessment of patients with lung complications due to COVID-19. In the case of clinical indication, the document recommends performing the CT scan immediately, without the fear of fetal damage.

Concerning breastfeeding, Li et al. provided further confirmation of the absence of vertical transmission through breast milk [2], [3]. While a previous study tested colostrum at the first feed [4], Li et al. also tested the absence of the virus at 5, 6 and 7 days after the delivery. Based on the studies already described above, several authors reiterate the implausibility of vertical transmission through breast milk [5], [6], [7], [8]. Xia et al. described 20 cases of children under 14 years old with COVID-19, including 3 under one month. The authors presume that the transmission may be linked to close contact with an infected person. The clinical manifestations in children are similar to those of adults, such as fever, cough, in some cases diarrhoea; the general symptomatology was however mild.

The Italian Society of Neonatology has recently published interim indications on "Breastfeeding and SARS-CoV-2 infection" [9]. The document, also endorsed by the Union of European Neonatal & Perinatal Societies (read the English version [10]), examines the existing literature, considers the different approaches present in the international context and gives indications on the management of mother and newborn during SARS-CoV-2 epidemic. These indications are aligned with CDC recommendations [11].

The previous document of the Collège National des Gynécologues et Obstétriciens Français on the taking of care of mothers with confirmed infection or waiting for  test result, published on 4 March, indicated a paediatric case-by-case evaluation of the possible mother-child dyad separation and the modalities of breastfeeding [12]. In the update of 15 March 2020, the CNGOF supports the positions of the Societé Française de Néonatologie and the Groupe de Pathologie Infectieurse Pédiatrique that "currently do not recommend mother-child separation and do not contraindicate breastfeeding". They suggest the use of a mask and hygiene measures for the mother; instead, no mask is recommended for the child [13].

The Association of Chinese Neonatologists [14] supports the positions already argued by other authors, recommending the separation of the mother from the newborn and the interruption of breastfeeding [15], [16], [17]; a series of 4 case studies reported the use of formula immediately after birth, in substitution of breast milk, in infants who subsequently tested negative to the swab [18].

The WHO and the CDC already released their position statements at the beginning of the epidemic, and reiterate the indications on breastfeeding and mother-baby contact.

Concerning newborns from suspected, probable or confirmed COVID-19 mothers, in the interim guidance of March 13, WHO reports [19] that:

• newborns should be fed according to the standards defined by the guidelines (i.e .: infant feeding standards are breastfeeding started within 1 hour of birth and continued exclusively for at least 6 months, then supplemented with adequate complementary feeding up to 2 years and over) while taking the necessary infection control and prevention measures
• mothers who breastfeed or practice skin-to-skin or KMC should adopt hygiene measures (use of a mask, hand hygiene, surface cleaning)
• basic psychosocial support and practical support for feeding infants should be offered to all pregnant women and mothers of young children
• when maternal clinical situation prevents her from taking care of her baby or continuing direct breastfeeding, mothers should be encouraged and supported for expressing breast milk, which should be administered safely to the baby (with control and prevention measures)
• mothers and newborns should be able to stay together and practice skin-to-skin contact, KMC and rooming-in day and night, especially after delivery and during breastfeeding, if they or their children are COVID-19 suspected, probable or confirmed
• parents, fathers, and caregivers who are separated from their children, and children who may need to be separated from their primary caregivers (mother, father) should have access to healthcare and non-healthcare professional, trained in mental health and psychological support.

The four Royal Colleges, Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Paediatrics and Child Health, Royal College of Anaesthetists, and the Obstetric Anaesthetists' Association have issued an interim guidance, constantly updated.

With regard to post-natal management and breastfeeding, the document reports [1]:

• The indications of the Chinese Commission are to isolate the infected mother and her baby for 14 days. This application of the precautionary principle to the mother and her healthy infant should not be undertaken lightly, given the potential detrimental effects on breastfeeding and bonding. Given the current limited evidence, we advise that women and healthy infants, not otherwise require neonatal care, are kept together with their mothers in the immediate post-partum period.
• A risks/benefits discussion with neonatologists and families to individualise care in babies that may be more susceptible is recommended (interim guidance).
• All children born to COVID-19 positive mothers should be closely and appropriately monitored and early involved in neonatal care, if necessary. Babies born to mothers testing positive for the swab should be followed up and surveilled after discharge.
• In the light of the current evidence, we advise that the benefits of breastfeeding outweigh any potential risks of transmission of the virus through breastmilk. The risks and benefits of breastfeeding, including the risk of holding the baby in close proximity to the mother, should be discussed with her (interim guidance).

The contents presented on this page were discussed with the Italian Regions during the scientific meeting "The new coronavirus 2019-COVID-19: state of the art" (March 18), of which a summary document edited by Serena Donati and Angela Giusti is available (pdf 817 kb).

References:

1. RCOG, RCM, RCPCH, RCOA, OOA (2020). Information for healthcare professionals Coronavirus (COVID-19) Infection in Pregnancy.
2. Li, Y., Zhao, R., Zheng, S., Chen, X., Wang, J., Sheng, X., … Sheng, J. (2020). Lack of Vertical Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, China. Emerging Infectious Diseases, 26(6), 2-5.
3. Li, Y., Zhao, R., Zheng, S., Chen, X., Wang, J., Sheng, X., … Sheng, J. (2020). Lack of Vertical Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, China. Emerging Infectious Diseases, 26(6), 200287.
4. Chen, H., Guo, J., Wang, C., Luo, F., Yu, X., Zhang, W., … Zhang, Y. (2020). Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet, 0(0).
5. Epicentro 27 February
6. Epicentro 4 March
7. Epicentro 12 March
8. Yang, H., Wang, C., & Poon, L. C. (2020). Novel coronavirus infection and pregnancy. Ultrasound in Obstetrics & Gynecology : The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology, 10–12.
9. Società Italiana di Neonatologia (SIN). ALLATTAMENTO e INFEZIONE da SARS-CoV-2 (Coronavirus Disease 2019 - COVID-19).
10. Union of European Neonatal & Perinatal Societies (UENPS). BREASTFEEDING and SARS-CoV-2 INFECTION (Coronavirus Disease 2019 - COVID-19). 
11. CDC. Pregnancy & Breastfeeding Information about Coronavirus Disease 2019. Page last reviewed: March 17, 2020
12. CNGOF. Prise en charge aux urgences maternité d’une patiente enceinte suspectée ou infectée par le coronavirus (COVID-19) - V1 (04/03/2020)
13. CNGOF. Prise en charge aux urgences maternité d’une patiente enceinte suspectée ou infectee par le coronavirus (COVID-19) - v1 (15/03/2020)
14. Li, F., Feng, Z. C., & Shi, Y. (2020). Proposal for prevention and control of the 2019 novel coronavirus disease in newborn infants. Archives of Disease in Childhood. Fetal and Neonatal Edition, 0(0), fetalneonatal-2020-318996.
15. 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.
16. Qiao, J. (2020). Comment What are the risks of COVID-19 infection in pregnant women?
17. 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).
18. Chen, Y., Peng, H., Wang, L., Zhao, Y., Zeng, L., Gao, H., & Liu, Y. (2020). Infants Born to Mothers With a New Coronavirus (COVID-19). Frontiers in Pediatrics, 8.
19. WHO. (2020). Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected.