COVID-19: pregnancy, delivery and breastfeeding - March 26th 2020
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 fourth update of the document on Coronavirus infection (COVID-19) and pregnancy . The main update is the introduction in the document of a section completely dedicated to the services caring for pregnant women after a period of isolation due to suspected symptoms or following recovery from an infection confirmed by SARS-CoV-2.
A Chinese case report  describes a suspected vertical transmission of the SARS-CoV-2 infection that could not be confirmed because of the late collection of the neonatal oropharyngeal swab, performed 36 hours after birth. On the other hand, the evidence to support the absence of vertical transmission of the SARS-CoV-2 virus from mother to infant is continuously increasing. A retrospective analysis of the clinical documentation of 9 women with a confirmed diagnosis of COVID-19 pneumonia, underwent a cesarean section in China, found no vertical transmission of the infection from mother to infant. The detection of the virus in amniotic fluid, umbilical cord blood and nasopharyngeal swab of newborns has always been negative . In another paper, the authors describe the clinical, laboratory and virological data of 38 Chinese women who contracted the COVID-19 infection in pregnancy and they confirm the absence of transplacental transmission of the infection .
Another study  reviews the evidence on Coronavirus infections during pregnancy, highlighting how the limited knowledge available is attributable to the SARS and MERS epidemics, which are responsible for serious maternal and neonatal outcomes, both in terms of morbidity and mortality. The authors underline that vertical transmission of the infection has never been demonstrated for both Coronaviruses responsible for the SARS and MERS epidemics, as opposed to what happened in Zika and Ebola virus infections.
An emerging topic in the literature on the new Coronavirus concerns the role and needs of healthcare professionals involved in the pandemic emergency. A BMJ news , taking up the recommendations of the RCOG, addresses the problem of health workers who are professionally exposed to the risk of contracting the disease during pregnancy.
Another study  concerns the topic of the COVID-19 pandemic from the point of view of maternity services health professionals and offers operational indications to prevent the spread of infections and to protect pregnant women by suggesting a review of the calendar of prenatal visits, appointments for ultrasound or cardiotocographic checks and a policy for outpatient services. The Interim Guidance  of the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) also offer indications for the management of SARS CoV-2 positive women during pregnancy and puerperium.
Considering the high contagiousness of the virus and the high probability of infection transmission through health professionals in close contact with patients, a work published in Chinese  recommends the adoption of strict protection measures referring to the operative setting in case of emergency cesarean. The indications include the establishment of a solid management system, effective disinfection and isolation measures and the strict implementation of operating procedures to prevent the iatrogenic transmission of the new coronavirus.
Other papers summarize indications on perinatal and neonatal management for the prevention and control of new Coronavirus infections [10,11].
In a retrospective review of the medical records of 17 Chinese women SARS CoV-2 positive who underwent cesarean section, Chen and collaborators  describe epidural and general anesthesia as safe and effective for patients and newborns.
A recent Italian study  describes the use of pulmonary ultrasound as a diagnostic imaging technique in the clinical evaluation of women with SARS CoV-2 with respiratory complications. The authors describe the possible use of the technique in obstetricians/gynecologists clinical practice. Another work summarizes the clinical recommendations for the prevention and management of COVID-19 infections in pregnancy and reviews the main organizational and care difficulties, highlighting the need and urgency to collect and disseminate epidemiological data on infection in pregnancy during the current pandemic .
A first systematic literature review  on COVID-19 infections in infants and children has been published and selected 45 relevant articles and letters. Of the total of COVID-19 infections diagnosed, 1-5% concern children, who have a less serious clinical course than the adult population. The most frequent symptoms are fever and respiratory signs that rarely result in pneumonia. Compared to adults, inflammatory markers are also less frequently altered. The therapy involves the administration of oxygen, inhalations, nutritional support and control of the hydro-electrolyte balance. The authors conclude that COVID-19 infection in children has a better course and prognosis than adults and that deaths are extremely rare.
To date, more and more studies show the absence of vertical transmission mother-child during pregnancy or breastfeeding [12,16, 17, 18, 5]. Cuifang et al. , present two cases of mothers with COVID-19 during the third trimester of pregnancy. Samples of maternal serum, cord blood, placental tissue, amniotic fluid, vaginal swab, breast milk and oropharyngeal swab from mother and newborn were collected. Except for the mothers' oropharyngeal swab which tested positive, the other elements analyzed were all negative. Although infants were separated from mothers immediately after birth, the authors provide evidence of a low risk of intrauterine vertical transmission and suggest the possible protective effect of maternal antibodies transmitted through breast milk on newborns, despite in these two cases the breastfeeding has been discouraged to avoid close contact.
More and more authors confirm the indication for breastfeeding for suspected and confirmed (symptomatic or asymptomatic) SARS-CoV-2 mothers. In their previous article published in The Lancet, Favre et al.  advised against breastfeeding. Responding in this regard to a comment by Schmid et al. , Baud reviews the authors' initial position in light of the new information available . The new indications include delayed cord clamping and non-removal of vernix caseosa up to 24 hours after birth. Breastfeeding during maternal infection COVID-19 is no longer contraindicated and appropriate hygiene measures should be taken. They also recommend, in cases where mother-baby separation is necessary, the breastmilk expression .
The Inter-Agency Standing Committee (IASC) interim guidance on the COVID-19 epidemic and more generally on emergencies, indicates for ill women to continue breastfeeding because the child who has already been exposed to the virus by the mother and/or family will benefit most from direct breastfeeding. Therefore, any interruption of breastfeeding can actually increase the infant’s risk of becoming ill and even of becoming severely ill .
Some Chinese authors continue to recommend the mother-infant separation "for at least two weeks", advising against direct breastfeeding, to "minimize the risk of viral transmission by avoiding longer and closer contact with the infected mother" .
On the contrary, the WHO, the British Royal Colleges and the CDC confirm the indication for breastfeeding [24,25,1]. About the postpartum, WHO recommends that “mothers and infants should be enabled to remain together and practise skin-to-skin contact, kangaroo mother care and to remain together and to practise rooming-in throughout the day and night, especially immediately after birth during establishment of breastfeeding”. The Royal Colleges indicate that “women and healthy infants, not otherwise requiring neonatal care, are kept together in the immediate post-partum period”. WHO and RCOG, on their websites, also offer this information to women and the general population through a series of questions and answers [26,27].
In the latest version of its interim indications, the Italian Society of Neonatology suggests to jointly manage mother and baby whenever possible, in order to facilitate the interaction and the starting of breastfeeding; if the mother is symptomatic and has a compromised clinical situation, mother and baby are transiently separated. The decision whether to separate mother and baby or not must be made for each dyad, taking into account "the informed consent of the mother, the logistical situation of the hospital and possibly also the local epidemiological situation relating to the spread of SARS-CoV-2." In case of separation of the infant from the mother, the use of fresh expressed breast milk is recommended, for which pasteurization is not indicated .
Several Italian newspapers report cases of newborn babies born healthy from SARS-COV-2 positive mothers and directly breastfed.
Italian Regions are developing their indications and clinical pathway for pregnant women and new mothers with SARS-COV-2 infection. There are differences, in particular in the management of the immediate postpartum. These differences can be linked to local, logistical and organizational factors, as well as to the epidemiological framework of the various areas affected.
Other components of maternity health care, are the territorial services and the support network for women, which play an increasingly important role during the COVID-19epidemic. Among the strategies aimed to reduce the access to hospitals and the risk of contagion for pregnant women, the scientific obstetric societies SYRIO and SISOGN recommend to reinforce the strategies of mother and child protected discharge after childbirth and to implement home clinical activities and support for the obstetric-neonatal area .
Moreover, they recommend the reinforcement of teleassistance services (ideally with video call) also to ensure counselling opportunities concerning specific information and support needs. The same strategies can be successfully adopted in pregnancy (for example with the offer of individual or group accompanying meetings at birth), puerperium and breastfeeding. Numerous Healthcare Authorities have activated maternity care and support services through video call and home visits; however, information relating to the offer of these services is not always easily accessible for users. Peer support groups also belong to some Healthcare Authorities which, in the case of Baby Friendly Communities recognized by UNICEF, are an integral part of the support offered in the local area. The network of mother-to-mother support groups has made available to new mothers the opportunity to participate in individual or group meetings electronically (video call or web meetings) and free of charge. A map of the groups is available on the Italian Breastfeeding Movement website .
The Saperidoc website has published a rich in-depth page on the topic of COVID-19 in pregnancy, childbirth, and puerperium . The page offers in-depth materials for health professionals and, as usual, popular materials intended for women. The latter include indications on the care paths offered by family counselling centres and other information materials. One of the themes is "staying at home with children" with suggestions and indications from the Centre for Child Health in Trieste; a section of games, readings, and music developed in collaboration with the Paediatric Cultural Association and a section with advice for parents and future parents, entitled: "The (precious) time of the coronavirus".
- Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Paediatrics and Child Health, Public Health England and Health Protection Scotland. Coronavirus (COVID-19) Infection in Pregnancy. Information for healthcare professionals. Version 4: Published Saturday 21 March 2020.
- Wang S, Guo L, Chen L, et al. A case report of neonatal COVID-19 infection in China [published online ahead of print, 2020 Mar 12]. Clin Infect Dis. 2020;ciaa225. doi:10.1093/cid/ciaa225
- Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395(10226):809-815. doi:10.1016/S0140-6736(20)30360-3
- Schwartz DA. An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes [published online ahead of print, 2020 Mar 17]. Arch Pathol Lab Med. 2020;10.5858/arpa.2020-0901-SA. doi:10.5858/arpa.2020-0901-SA
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- Rimmer A. COVID-19: pregnant doctors should speak to occupational health, say experts. BMJ. 2020;368:m1104. Published 2020 Mar 18. doi:10.1136/bmj.m1104
-  Boelig RC, Saccone G, Bellussi F, Berghella V. MFM Guidance for COVID-19, Am J Obst Gynecol MFM, 2020, 100106, ISSN 2589-9333, https://doi.org/10.1016/j.ajogmf.2020.100106.
- Poon LC, Yang H, Lee JCS, et al. ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals [published online ahead of print, 2020 Mar 11]. Ultrasound Obstet Gynecol. 2020;10.1002/uog.22013. doi:10.1002/uog.22013
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- Liu Y, Chen H, Tang K, Guo Y. Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect. 2020 Mar 4. pii:S0163-4453(20)30109-2. doi: 10.1016/j.jinf.2020.02.028. [Epub ahead of print] PubMed PMID: 32145216
- Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients. Can J Anaesth. 2020 Mar 16. doi: 10.1007/s12630-020-01630-7. [Epub ahead of print] PubMed PMID: 32180175; PubMed Central PMCID: PMC7090434
- Moro F, Buonsenso D, Moruzzi MC, Inchingolo R, Smargiassi A, Demi L, Larici AR, Scambia G, Lanzone A, Testa AC. How to perform lung ultrasound in pregnant women with suspected COVID-19 infection. Ultrasound Obstet Gynecol. 2020 Mar 24. doi: 10.1002/uog.22028. [Epub ahead of print] PubMed PMID: 32207208.
- Liang H, Acharya G. Novel corona virus disease (COVID-19) in pregnancy: What clinical recommendations to follow? Acta Obstet Gynecol Scand. 2020 Apr;99(4):439-442. doi: 10.1111/aogs.13836. Epub 2020 Mar 5. PubMed PMID: 32141062.
- Ludvigsson JF. Systematic review of COVID-19 in children show milder cases and a better prognosis than adults. Acta Paediatr. 2020 Mar 23. doi: 10.1111/apa.15270. [Epub ahead of print] PubMed PMID: 32202343.
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- Han, Y. & Yang, H. The transmission and diagnosis of 2019 novel coronavirus infection disease (COVID-19): A Chinese perspective. J. Med. Virol. 1–6 (2020). doi:10.1002/jmv.25749
- Mullins, E., Evans, D., Viner, R. M., O’Brien, P., & Morris, E. (2020). Coronavirus in pregnancy and delivery: rapid review. Ultrasound in Obstetrics & Gynecology : The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. https://doi.org/10.1002/uog.22014
- Cuifang, F. et al. Perinatal Transmission of COVID-19 Associated SARS-CoV-2: Should We Worry? J. Chem. Inf. Model. (2020).
- Favre, G., Pomar, L., Qi, X., Nielsen-Saines, K., Musso, D., & Baud, D. (2020). Guidelines for pregnant women with suspected SARS-CoV-2 infection. The Lancet Infectious Diseases, 0(0). https://doi.org/10.1016/S1473-3099(20)30157-2
- Schmid, M. B., Fontijn, J., Ochsenbein-Kölble, N., Berger, C., & Bassler, D. (2020). COVID-19 in pregnant women. The Lancet Infectious Diseases, 3099(20), 30175. https://doi.org/10.1016/S1473-3099(20)30175-4
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- IFRC, IOM, UNHCR, WHO. Interim Guidance SCALING-UP COVID-19 OUTBREAK READINESS AND RESPONSE OPERATIONS IN HUMANITARIAN SITUATIONS Including Camps and Camp-Like Settings. 1–8 (2020).
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- SIN (2020). Allattamento e infezione da SARS-CoV-2 - Indicazioni ad interim della Società Italiana di Neonatologia
- SYRIO, SISOGN. (2020). Position paper. Emergenza COVID-19 e l’assistenza nel territorio in gravidanza, nel parto ed il puerperio.
- Saperidoc. COVID-19 in gravidanza, parto e puerperio. Informazioni sul nuovo coronavirus (SARS-CoV-2) e sulla gestione delle donne gravide e dei loro neonati con diagnosi sospetta o confermata di malattia COVID-19
- visit the index page about COVID-19: pregnancy, delivery and breastfeeding