Coronavirus

COVID-19: pregnancy, delivery and breastfeeding - April 2nd 2020

The vertical transmission of Coronavirus infection (transmission from mother to child before birth or intrapartum), has been explored and discussed on the JAMA issue of March 26, which reported three contributions [1,2,3] supporting this possibility and an editorial [4] that argues the strength of available evidence to date. Previous publications related to childbirths that occurred in China described the absence of evidence supporting the vertical transmission. Amniotic fluid, cord blood, newborns nasopharyngeal swabs, placental and vaginal swabs, and blood samples of positive COVID mothers had always been negative in the detection for the SARS-CoV-2 virus [5,6,7,8,9,10,11]. The new studies describe that SARS-CoV-2 IgM have been detected in serum of some newborns of positive COVID-19 mothers at birth. The anal swab was performed in three infants, with a positive result on days 2 and 4 and a negative result on day 6-7 [3]. Since IgM are unable to cross the placenta, due to their macromolecular structure, their detection is suggestive of a neonatal immune response, secondary to an infection that occurred in the uterus. However, none of the newborns tested positive for RT-PCR swabs performed at birth and repeated up to 16 days of life. In his editorial, Kimberlin [4] says that negative serology does not allow excluding the transmission of the virus after birth, and underlines how the diagnosis of congenital infections through IgM research poses problems related to possible false positives and negatives of the method that is less reliable than molecular diagnostic tests. The kinetics of the decrease in SARS-CoV-2 IgM described in the works is also much faster than that observed in other congenital transmission infections. The editorial, therefore, concludes that before confirming a possible vertical transmission of the SARS-CoV-2 virus, greater evidence is needed than described in the presented cases.

Two new Chinese works [12,13] describe the maternal-fetal management of SARS-CoV-2 positive patients and a Singapore publication [14] outlines a frame of reference for Hub centres called to safely assist positive COVID 19 patients and healthcare professionals.

The RCOG, in collaboration with the Royal College of Midwives, Royal College of Paediatrics and Child Health, Royal College of Anaesthetists, and the Obstetric Anaesthetists' Association, has published the fifth update of the document on Coronavirus infection (COVID-19) and pregnancy [15]. The main updates relate to a reference to the suspicion of vertical transmission, which has already been described in this update, and a section dedicated to healthcare professionals who assist suspected or confirmed COVID-19 pregnant women, with indications of obstetric and gynecological surgery. In addition to the organizational aspects of operating rooms, the update deepens the indications for the use of personal protective equipment (PPE) for healthcare professionals. The RCOG specifies that the only obstetrical care procedure that exposes to the risk of aerosol is intubation in case of general anesthesia for cesarean section. The RCOG's indications for vaginal delivery attendance, therefore, suggest the use of the surgical mask, while the update of 28 March of the ISS COVID-19 Report no. 2/2020 [16] states that “even in care settings where CPAP/NIV is not practiced, it is however preferable, where available, to use facial filters based on an appropriate risk assessment that also takes into account the significant increase in exposure time, carried out at the structure level by the employer with the collaboration of the head of the prevention and protection service and the competent doctor”. Consequently, based on these indications, it is preferable, where available, the use of an FFP2 mask rather than a surgical mask for vaginal delivery attendance.

The International Confederation of Midwives (ICM) has issued a statement on the care of women and newborns, aimed at midwives, professionals, and decision-makers involved in birth care. The document expresses concern about the introduction of inappropriate care modalities in response to the COVID-19 pandemic and recommends the respect for the women’s and newborn’s rights and the adoption of evidence-based care practices [17].

The Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) has published a document describing the indications for the anesthesiological-resuscitation management of patients with suspected or ascertained SARS CoV2 (COVID-19) infection in the peri partum. The first interim version of the document reviews pregnancy care, vaginal delivery, cesarean section and post partum, also describing the indications for the patient's transport and clinical management [18].

The Italian Society of Obstetric and Gynecological Ultrasound and Biophysical Methodologies (SIEOG) issued recommendations regarding the planning of ultrasound activity, the protection of health workers dedicated to performing ultrasound examinations, and the prevention of contamination, the cleaning, and the disinfection of clinics and ultrasound equipment related to the SARS-CoV2 virus outbreak [19].

In an article published in the Italian Journal of Gynecology & Obstetrics, Franchi et al. summarize the existing literature on gynecological and obstetric management of patients with COVID-19. The authors resume the indications emerging from the Chinese case reports and from the main international agencies, including CDC, British Royal Colleges and WHO [20].

With regard to breastfeeding, some Chinese authors, as already stated in previous publications, argue that women with suspected or confirmed infection, with or without symptoms, should not breastfeed. Infants with suspected or confirmed SARS-COV-2 infection should be temporarily separated or isolated [21,12,22].

Based on the absence of detection of the virus in breast milk, Dashraath et al. claim that breastfeeding is not contraindicated and that the mother should comply with the recommended hygiene measures to avoid the risk of transmission through breath droplets [14].

The indications of the CDC [23,24] and the World Health Organization [25] remain unchanged, and those of the English Royal Colleges [15] are confirmed.

Among the updates from the Royal Colleges, a recommendation has been modified including both parents in the decision-making process of the risks and benefits assessment in the management of breastfeeding, in case one of the parents is infected [15]. With regard to parents and caregivers who may be temporarily separated from their children, the WHO recommends to provide adequate support from personnel, health and non-healthcare professionals, properly trained for mental health and psychosocial support [25].

In an Insight into Practice and Policy published in the Journal of Human Lactation, Marinelli describes the effects of the pandemic on the management of donated human milk. The contact persons of Milk Banks in China, Italy and the USA have been reached [26]. In China, both donation and demand for human milk have decreased because of the pandemic; the screening measures for the donation have been increased and the collection system takes place directly into the hospital. Home-collected milk is not accepted. In Italy, donations have decreased, probably because women prefer not to go to the hospital; the alternative, represented by home collection, has suffered a setback due to the need to dedicate all staff to emergency management. In Milan, the milk donation system is substantially suspended. As for the milk banks in the USA, at the moment there seem to be no effects on the donation or on the offer. The same article incorrectly reports information on the detection of COVID-19 antibodies in one infected woman milk. Actually, the only research carried out on antibodies is currently related to the previous SARS epidemic [27]. The study promoted by ISS will contribute to the detection of these antibodies in colostrum and breast milk [28].

In the document issued on 30 March 2020 on infant feeding in the context of COVID-19, UNICEF, Global Nutrition Cluster and Global Technical Assistance Mechanism for Nutrition [29] resume the WHO indications with a specific reference to adherence to the International Code for the marketing of breastmilk substitutes [30] and to the Guidance on ending the inappropriate promotion of foods for infants and young children [31]. In particular, they draw attention to the risks of donating artificial formulas for infants and products for early childhood and refer to the application of the Operating Guide for Infant Feeding in Emergencies. They also invite to leverage social media, the web and mass media to provide information and counteract prejudice and misinformation. In Italy, collection initiatives and formula donations have also been reported, in contrast to what is currently indicated [32,33]. (read Epicentro's Section on Infant Feeding in Emergencies - AINE)

References

1. Dong L, Tian J, He S, Zhu C, Wang J, Liu C, Yang J. Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. JAMA. 2020 Mar 26. doi: 10.1001/jama.2020.4621. [Epub ahead of print] PubMed PMID: 32215581.
2. Zeng H, Xu C, Fan J, Tang Y, Deng Q, Zhang W, Long X. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA. 2020 Mar 26. doi: 10.1001/jama.2020.4861. [Epub ahead of print] PubMed PMID: 32215589.
3. Zeng L, Xia S, Yuan W, Yan K, Xiao F, Shao J, Zhou W. Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr. 2020 Mar 26. doi: 10.1001/jamapediatrics.2020.0878. [Epub ahead of print] PubMed PMID: 32215598.
4. Kimberlin DW, Stagno S. Can SARS-CoV-2 Infection Be Acquired In Utero?: More Definitive Evidence Is Needed. JAMA. 2020 Mar 26. doi: 10.1001/jama.2020.4868. [Epub ahead of print] PubMed PMID: 32215579.
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14. Dashraath P, Jing Lin Jeslyn W, Mei Xian Karen L, Li Min L, Sarah L, Biswas A, Arjandas Choolani M, Mattar C, Lin SL. Coronavirus Disease 2019 (COVID-19) Pandemic and Pregnancy. Am J Obstet Gynecol. 2020 Mar 23. pii: S0002-9378(20)30343-4. doi: 10.1016/j.ajog.2020.03.021. [Epub ahead of print] PubMed PMID: 32217113.
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