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Epidemiology for public health
Istituto Superiore di Sanitŕ

 

Epidemiology for public health - ISS

COVID-19: pregnancy, delivery and breastfeeding - April 23th 2020

Following the spread of the pandemic in the United States, the literature continues to be enriched by contributions on COVID-19 infection in pregnancy from overseas. A cohort of 43 women with COVID-19 infection diagnosis during pregnancy, hospitalized in 2 New York hospitals [1], has similar clinical conditions to those found in the general population, with 83% of mild, 9.3% severe, and 4.7% critical disease. The study describes in detail the course of infections and pre, intra, and post partum care. The authors propose to screen all women who are hospitalized in obstetrics units using nasopharyngeal tests to ensure the identification of positive and asymptomatic subjects, in order to protect patients, family members, and health professionals, make the best use of often insufficient PPE, reassure negative mothers and provide information to neonatologists in case of positive asymptomatic mothers. The execution of the test on all pregnant women attending maternity services could, in fact, identify a subgroup of asymptomatic or pre-symptomatic women who are currently underrepresented in the general population due to difficulties in supplying and carrying out the tests.

 

A US narrative review [2] summarizes good care practices for COVID-19 positive women in pregnancy and during childbirth and for their infants. An original study [3] examines female hospitalizations that occurred in 14 hospitals in the New York State during March 2020, which amount to a total of 21,980, of which 3,064 pregnant or puerperium women, and 19,299 non-pregnant women. Between the first and fourth weeks of March, the percentage of hospitalizations of women who tested positive for SARS-CoV-2 in pregnancy or puerperium increased from 0.14% to 5.65%, while among non-pregnant women it increased from 1.21% to 56.79%. The higher prevalence of asymptomatic SARS-CoV-2 positive women in the female general population compared to pregnant women is attributed to their more advanced age, which makes them more often symptomatic than pregnant women, who are hospitalized mainly for childbirth rather than for the symptoms of COVID-19 infection.

 

An Iranian case report [4] describes the first case of maternal death due to COVID-19 infection in pregnancy. The 27-year-old patient had fever, myalgia, and coughs during the 30th week of gestation. The X-ray and pulmonary CT did not appear pathognomonic for COVID pneumonia. The laboratory showed lymphopenia and increased PCR accompanied by worsening clinical conditions of respiratory distress that required mechanical ventilation and orotracheal intubation until it became complicated in MOF and maternal death. The autopsy confirmed viral pneumonia and ARDS.

 

With regard to the current problems related to the availability and use of PPE in the obstetric field, Rasmussen et al. thoroughly examine the measures to prevent the risk of SARS-CoV-2 virus infection among professionals caring for pregnancy and childbirth [5]. The paper is full of documented information and concludes that the most effective measures for prevention consist of a bundle of activities that involve: the accurate hygiene of hands and hospital environments; the appropriate use of PPE, ensured by specific training for healthcare professionals; the identification of cases, also by the screening of all pregnant women who attend the healthcare facilities regardless of the presence or absence of symptoms; the regular use of the mask by all hospitalized women even during childbirth; physical distancing and careful isolation of positive patients.

 

The problem of PPE in the obstetrical field is closely related to the universal screening policies for all women attending maternity services, and to opening or closing the access to the wards and the delivery rooms for family members of women who are hospitalized to give birth.

 

A letter from a group of perinatal mental health experts addresses the issue of family members and visitors not being allowed to enter the obstetrics wards and delivery rooms in New York [6]. The authors conclude that in this moment of great spread of the virus, scarcity of PPE, and serious crisis of the health services, the risk of psychological relapses due to the lack of access of a trusted person of the woman during the birth is lower than that of the transmission of the infection and, therefore, they consider that the closure policies adopted by some maternity services are acceptable. They also suggest that, in order to mitigate the effects of this separation, strategies developed in different circumstances may be applied, for example with women giving birth far from their partners employed in U.S. military forces. The letter ends with an invitation for those facilities that will face this situation in the USA to timely organize themselves for the provision of remote maternal and parental support services, both in the prenatal and postpartum periods, making sure to promptly resume the usual reception measures for women’s family members as soon as the emergency phase has ended.

 

About this aspect, the British Royal Colleges in the last update of April 17 corroborate the indication on the presence of a single asymptomatic person, chosen by the woman, during labor and delivery, as this presence makes a significant difference for the safety and the well-being of women during childbirth. The person chosen by the woman should remain close to her all the time, without moving within the unit, and should adopt the preventive measures provided by the structure [7].

 

Two systematic reviews on COVID-19 in pregnancy have been published. One concerns the whole spectrum of Coronavirus infections (SARS, MERS, COVID-19) and aims to describe the main maternal and neonatal outcomes [8]. The studies solely on COVID-19 infection included in the review are limited in number (n = 6), describe 41 cases in total, and, according to the authors, present methodological limitations that could compromise the conclusions of the work.

 

The second review [9] addresses the same topic and includes 6 studies, of which only 2 are in common with the previous one, for a total of 51 pregnant women affected by COVID-19. Also in this review, the assessment of the methodological quality of the publications included shows some critical issues and only one of the 6 papers meets the predefined quality criteria. Therefore, the authors did not perform a meta-analysis and simply describe and summarize the main results and the clinical implications of the case series examined.

 

The main news of the last British Royal Colleges’ update regards a new paragraph on the effects of the virus in pregnant women, describing articles already commented in the current summary and in that one published last week on the EpiCentro webpage. A warning on the possible increase of venous thromboembolism risk during a COVID-19 infection in pregnancy was also included. Paragraph 5, “Advice for services caring for women following isolation for symptoms, or recovery from confirmed COVID-19”, includes recommendations for care in pregnancy and puerperium. These include ultrasound surveillance of fetal growth in women with COVID-19 infection and prescription of low-molecular-weight heparin for at least 10 days to all women discharged both after vaginal birth and after caesarean section [7].

 

The vertical transmission remains unconfirmed [1,10,11,12,13] although there are some articles suggestive of this possibility [14,15]. In cases of newborns that have tested positive, the symptoms remain mild or moderate [16]. The ISS report “Characteristics of COVID-19 patients dying in Italy” of 20 April reports only one case of death under one year of age in a child with severe comorbidity [17].

 

Breslin et al. [1] describe 18 infants from positive mothers; the babies were negative, except for one case with an inconclusive result, and in good clinical condition. Breastfeeding was encouraged by respecting the hygiene rules and the social distancing recommended by the CDC [18]. Other authors report cases of negative and asymptomatic newborn babies from positive mothers [10,11]. Even in cases where the newborn showed moderate clinical symptoms, he tested negative for the virus in several biological samples.

 

The analysis of the breast milk of a positive COVID mother and a 27-day-old newborn baby girl, also positive, tested negative for the detection of the virus. Other authors confirm the absence of the virus in breast milk [10].

 

Spatz, in an editorial, offers guidance on breastfeeding by reviewing the scientific and biological rationale for the protection and promotion of the use of human milk and breastfeeding. The author underlines the importance of supporting the family to support the mother in the first two weeks after birth in order to optimize her resources and capacity for breastfeeding [19].

 

Salvatori et al. report the first two cases of a mother-newborn dyad that came in the pediatric emergency room. Mothers and babies were SARS-CoV-2 positive, probably infected at the same time by a third person. Neither mothers nor infants needed intensive care but, as a precaution, the babies were separated from paucisymptomatic mothers. The milk of both mothers was analyzed and no trace of the virus was detected. For this reason, the authors conclude that there is no indication of separation and interruption of breastfeeding. In cases where direct breastfeeding is not possible, the use of expressed breast milk should be considered [20].

 

Among the Italian documents and updates, SIAARTI has published the second version of the “Indications for the anesthesiological-resuscitation management of patients with suspected or confirmed SARS-CoV-2 (COVID-19) infection in the peripartum” [21].

 

The documents on the topic of COVID in pregnancy, childbirth, and breastfeeding are available on the websites of scientific societies. In particular, AOGOI has collected clinical protocols and care pathways produced by some services and Regions [22].

 

References
  1. Breslin N, Baptiste C, Gyamfi-Bannerman C, Miller R, Martinez R, Bernstein K, Ring L, Landau R, Purisch S, Friedman AM, Fuchs K, Sutton D, Andrikopoulou M, Rupley D, Sheen JJ, Aubey J, Zork N, Moroz L, Mourad M, Wapner R, Simpson LL, D'Alton ME, Goffman D. COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals. Am J Obstet Gynecol MFM. 2020 Apr 9:100118. doi: 10.1016/j.ajogmf.2020.100118. [Epub ahead of print] PubMed PMID: 32292903; PubMed Central PMCID: PMC7144599
  2. Dotters-Katz SK, Hughes BL. Considerations for Obstetric Care during the COVID-19 Pandemic. Am J Perinatol. 2020 Apr 17. doi: 10.1055/s-0040-1710051. [Epub ahead of print] PubMed PMID: 32303077
  3. Tekbali A, GrĂĽnebaum A, Saraya A, McCullough L, Bornstein E, Chervenak FA. Pregnant versus non-pregnant SARS-CoV-2 and COVID-19 Hospital Admissions: The first 4 weeks in New York. Am J Obstet Gynecol. 2020 Apr 15. pii: S0002-9378(20)30437-3. doi: 10.1016/j.ajog.2020.04.012. [Epub ahead of print] PubMed PMID: 32304691; PubMed Central PMCID: PMC7158836.
  4. Karami P, Naghavi M, Feyzi A, Aghamohammadi M, Novin MS, Mobaien A, Qorbanisani M, Karami A, Norooznezhad AH. Mortality of a pregnant patient diagnosed with COVID-19: A case report with clinical, radiological, and histopathological findings. Travel Med Infect Dis. 2020 Apr 11:101665. doi: 10.1016/j.tmaid.2020.101665. [Epub ahead of print] PubMed PMID: 32283217; PubMed Central PMCID: PMC7151464
  5. Jamieson DJ, Steinberg JP, Martinello RA, Perl TM, Rasmussen SA. Obstetricians on the Coronavirus Disease 2019 (COVID-19) Front Lines and the Confusing World of Personal Protective Equipment. Obstet Gynecol. 2020 Apr 16. doi: 10.1097/AOG.0000000000003919. [Epub ahead of print] PubMed PMID: 32304512
  6. Hermann A, Deligiannidis KM, Bergink V, Monk C, Fitelson EM, Robakis TK, Birndorf C. Response to SARS-Covid-19-related visitor restrictions on labor and delivery wards in New York City. Arch Womens Ment Health. 2020 Apr 15. doi: 10.1007/s00737-020-01030-2. [Epub ahead of print] PubMed PMID: 32296947
  7. Royal College of Obstetricians and Gynaecologists, The Royal College of Midwives UK, Royal College of Paediatrics and Child Helath, Royal College of Anaesthetists & Obstetric Anaesthetists’ Association. Coronavirus ( COVID-19 ) Infection in Pregnancy Information for healthcare professionals. (2020).
  8. Di Mascio D, Khalil A, Saccone G, Rizzo G, Buca D, Liberati M, Vecchiet J, Nappi L, Scambia G, Berghella V, D'Antonio F. Outcome of Coronavirus spectrum infections (SARS, MERS, COVID 1 -19) during pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM. 2020 Mar 25:100107. doi: 10.1016/j.ajogmf.2020.100107. [Epub ahead of print] Review. PubMed PMID: 32292902; PubMed Central PMCID: PMC7104131
  9. Della Gatta AN, Rizzo R, Pilu G, Simonazzi G. COVID19 during pregnancy: a systematic review of reported cases. Am J Obstet Gynecol. 2020 Apr 17. pii: S0002-9378(20)30438-5. doi: 10.1016/j.ajog.2020.04.013. [Epub ahead of print] Review. PubMed PMID: 32311350
  10. Liu, W. et al. Clinical characteristics of 19 neonates born to mothers with COVID-19. Front. Med. (2020). doi:10.1007/s11684-020-0772-y
  11. Lowe, B. & Bopp, B. COVID-19 vaginal delivery - a case report. Aust. N. Z. J. Obstet. Gynaecol. (2020). doi:10.1111/ajo.13173
  12. Peng, Z. et al. Unlikely SARS-CoV-2 vertical transmission from mother to child: A case report. J. Infect. Public Health 4–6 (2020). doi:10.1016/j.jiph.2020.04.004
  13. Yang, P. et al. Clinical characteristics and risk assessment of newborns born to mothers with COVID-19. J. Clin. Virol. 127, 104356 (2020).
  14. Alzamora, M. C. et al. Severe COVID-19 during Pregnancy and Possible Vertical Transmission. Am. J. Perinatol. 1, (2020).
  15. Zamaniyan, M. et al. Preterm delivery in pregnant woman with critical COVID-19 pneumonia and vertical transmission. Prenat. Diagn. (2020). doi:10.1002/pd.5713
  16. Han Seon, M. et al. Sequential analysis of viral load in a neonate and her mother infected with SARS-CoV-2. (2020).
  17. Palmieri, L. et al. Characteristics of COVID-19 patients dying in Italy Report based on available data on March 20 th, 2020. 4–8 (2020).
  18. Considerations for Inpatient Obstetric Healthcare Settings | CDC.
  19. Spatz, D. L. Using the Coronavirus Pandemic as an Opportunity to Address the Use of Human Milk and Breastfeeding as Lifesaving Medical Interventions. J. Obstet. Gynecol. neonatal Nurs. JOGNN 112–113 (2020). doi:10.1016/j.jogn.2020.03.002
  20. Salvatori, G. et al. Managing COVID-19-Positive Maternal–Infant Dyads: An Italian Experience. Breastfeed. Med. 15, 3–4 (2020).
  21. SocietĂ  Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva. Indicazioni per la gestione anestesiologico-rianimatoria di pazienti con sospetta o accertata infezione da sars-cov-2 (covid-19) nel peripartum. 2, (2020).
  22. Aogoi | Aogoi.

Publication date: 23 April 2020

Authors: Angela Giusti, Serena Donati, Francesca Zambri e Letizia Sampaolo, Centro nazionale per la prevenzione delle malattie e la promozione della salute - ISS