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Epidemiology for public health
Istituto Superiore di Sanità

 

Epidemiology for public health - ISS

COVID-19: pregnancy, delivery and breastfeeding - April 30th 2020

A study [1] describes the maternal and neonatal outcomes of 116 pregnant women with COVID-19 infection in order to assess the clinical features, pregnancy outcomes, and the risk of vertical transmission of the SARS-CoV-2 virus from mother to fetus. The authors define it as the largest case series available in the literature. It is a retrospective study that examined the medical records of 116 women in 25 Chinese hospitals from January 20 to March 24, 2020. The median gestational age is 38 weeks, the most common symptoms are fever and cough, and 23% of patients are asymptomatic at the time of hospitalization. In China, almost all pregnant women with COVID-19 infection underwent X-ray imaging, and lung imaging abnormalities were detected in 96% of the cases examined, but only 8 women developed severe pneumonia and no maternal deaths were recorded. A case of severe asphyxiation has resulted in neonatal death. Due to the number of case series, the work describes in detail the clinical and care aspects of mothers and babies. The authors conclude that SARS-CoV-2 virus infection in pregnant women has clinical characteristics similar to that of non-pregnant women with COVID-19 pneumonia; the risk of spontaneous abortion and preterm birth has not increased, and in women who developed the infection in the third trimester of pregnancy there is no evidence of vertical transmission of the virus from mother to infant. Other studies continue to demonstrate the absence of vertical transmission [1,2,3,4,5,6].

 

An Italian work [7] describes the intrapartum care offered to 42 women tested positive for COVID-19 infection during pregnancy who gave birth in 12 hospitals in northern Italy, between March 1 and 20, 2020. Clinical data were extracted from medical records. 57.1% of women (n=24) gave birth vaginally, 18 women underwent elective cesarean section, in 8 cases for indications not related to the COVID-19 infection. In 45.2% of patients, pneumonia was diagnosed with mainly mild-moderate clinical symptoms and 4 were admitted to intensive care units. A total of 3 newborns tested positive for the virus, two due to probable contamination during the postpartum period and one following an operative vaginal birth, but also, in this case, it is not possible to exclude infection in the immediate postpartum. The authors conclude the discussion of the results by stating that caesarean sections should be reserved for women with severe respiratory impairment and that further evidence is needed to safely exclude an intrapartum transmission of the SARS-CoV-2 virus, whose risk, if present, seems very limited. The issue of PPE for healthcare personnel in areas characterized by a high prevalence of infection is underlined as a priority, also in light of the observation of cases with symptoms that arose only after childbirth.

 

A narrative review selected 33 studies examining a total of 385 pregnant women with COVID-19 infection [3]. The clinical conditions were defined as mild in 95.6% of cases, severe in 3.6%, and critical 0.8%. There were 17 hospitalizations in intensive care units, of which 6 required mechanical ventilation, and to date, only one case of maternal death has been described. A total of 252 childbirths were recorded, of which 69.4% occurred by cesarean sections, and 30.6% vaginally. Of the 256 newborns, 4 tested positive for the RT-PCR test, and a total of 2 deaths in utero and one neonatal death were recorded. The authors conclude that COVID-19 infection in pregnancy appears to have a clinical presentation and severity similar to that of non-pregnant women and does not appear to be associated with unfavorable maternal or perinatal outcomes.

 

Some Chinese reports describing in detail the care pathways of small series of cases continue to be published, reporting the clinical characteristics and maternal and neonatal outcomes of positive SARS-COV-2 mothers [2,8,9].

 

A BMJ news [10] wonders what is the real prevalence of asymptomatic women on the total number of COVID-19 positive pregnant women at the time of hospitalization for childbirth. The few data available in the literature are related to limited cases that reveal very high proportions of asymptomatic women, equal to 29/33 in 2 hospitals in New York and 130/166 in a Chinese study.

 

A brief communication [11] describes a possible increase in the incidence of hydatidiform mole cases in a third-level hospital in Egypt during the pandemic. However, no quantitative data is reported to support the observation. The authors hypothesize a causal link between the viral infection and the condition and report a series of etiopathogenetic hypotheses of a predominantly immunological nature. The recommendation for clinical practice involves testing for the detection of the SARS virus in women diagnosed with hydatidiform mole.

 

The aspects relating to the pharmacological treatment of COVID-19 infection in pregnancy are poorly discussed in the literature due to the limited evidence available. An interesting French work [12], pre-printed on BJOG, describes the indications and the safety and efficacy profile of the drugs used in pregnant women suffering from COVID-19 with respiratory symptoms. Since pregnant women are not included in the ongoing study protocols, the authors underline the importance of sharing the experiences of different health systems between countries to define the best therapeutic approaches.

 

A Chinese narrative review [13] describes the pathophysiological foundations that make pregnant women easily susceptible to respiratory viral infections and reviews the main classes of drugs that can be used in the therapeutic setting. Unlike the French work, the authors do not refer to protocols that can be used in clinical practice and merely describe the biological basis of the use of the various active ingredients.

 

Literature related to the care organization in the birth path during the pandemic is growing. In view of the next phase 2, it is interesting to read the German article [14] that describes the experience of a great Maternity Unit in Bavaria where, in March, the spread of the SARS-CoV-2 virus occurred among health personnel. The work summarizes the strategy and interventions adopted to control the epidemic outbreak, describing the tracing and control operations of positive people and their contacts. The measures adopted include testing for all contacts of identifiable positive subjects; use of masks by all the staff; continuous monitoring of sickness absences, both of internal and external staff, such as laundry or catering staff; measures to ensure social distancing in all common areas; controls to verify compliance with hygiene, and continuous staff training on prevention measures; direct and transparent communications to both healthcare professionals and patients. About the contact tracing involving healthcare professionals, on April 9, 2020, the ECDC produced a technical report [15], which is also available in Italian [16].

 

A brief communication [17] outlines the organizational aspects developed by a team of Chinese anesthesiologists in case of need for emergency cesarean section. The procedures described aim to minimize the risk of contagion for healthcare professionals and optimize the care procedures for the execution of anesthesia in positive COVID-19 women.

 

John Tingle [18], professor at the University of Birmingham, examines some contents of the reports produced by the RCOG and the RCM on obstetric care in the United Kingdom during the SARS-CoV-2 epidemic, in order to discuss aspects related to the patient safety, the communication, and the risk of possible medico-legal disputes.

 

To conclude this deepening on the organizational aspects, we point out two contributions [19,20] introducing the problem of guaranteeing and maintaining an appropriate level of essential services for reproductive health during the emergency caused by the pandemic. The care provision during pregnancy, childbirth, and puerperium and services for contraception and voluntary abortion, as well as those for sexually transmitted diseases, prevention, and support for women victims of violence, cannot be considered a luxury and must be kept operational even in countries with limited economic resources to face the emergency.

 

About public health research, we have selected an interesting comment [21] published in The Lancet, which reviews the reasons why research projects on pregnant women during the COVID-19 pandemic represent an extraordinary opportunity for the production of knowledge useful for action. The authors recall the need for cooperation between countries in order to ensure an answer to the numerous research questions still open on COVID-19 infection and on its possible effects on pregnant women and newborns.

 

With regard to clinical research, a US study [22] examines the available evidence on the transmission of SARS-CoV-2 virus in animal models; the congenital and perinatal infections affecting humans, and caused by other Coronaviruses; and the limited and inconclusive evidence available on the possible vertical transmission of the SARS-CoV-2 in pregnancy. The authors define research on prenatal and perinatal modality of transmission of SARS-CoV-2 virus as a public health priority.

The Cultural Association of Pediatricians has published in the ACP Notebooks a special edition dedicated to COVID-19 which reviews the evolution of indications from January to the present day, addressing issues related to infants and young children [23].

 

An editorial by Breindhal et al [24], also supported by the heads of the Danish neonatal departments, reports the dilemmas and priorities of COVID-19 management in Neonatal Intensive Care. The questions that the authors propose are:

  • How is it possible to classify the mother's condition without a rigid case definition and knowledge of the course of the disease?
  • How can the extremely important bond between mother and baby, the initiation of breastfeeding, and the sensorineural stimulation in the immediate post-natal period being guaranteed if infected mothers are separated from their babies?
  • How is it possible to manage potentially infected mothers, family members, and infants in a NICU, in which parents are to be considered an integral part of the care process, even in the most critical infants, and not just visitors?
  • How is it possible to continue to follow the principles of Family Centered Care (FCC) and the Newborn Individualized Development and Assessment Program (NIDCAP) if the child is isolated from his parents?
  • How will NICU staff protect themselves and their families from a highly contagious disease without compromising the sick child and parents?

The authors suggest three guiding principles for taking care of families with COVID-19 in NICUs, “without compromising the values and fundamental prerequisites for optimal management of hospitalization”. The first is a basic principle, which provides for the non-separation of the family unit unless the parents have productive symptoms and are unable to follow the NICU guidelines. The second is the precautionary principle, which provides for considerations on the degree of development of the newborn, on the therapeutic challenges, on the type and severity of the pathology, and on the expected duration of hospitalization. Must be also considered the other hospitalized infants, their parents, and staff. Strict adherence to preventive measures by parents and the use of PPE by staff is important for the safety of the whole department, including the safety of operators and their families while maintaining a high quality of care. Finally, the holistic principle considers the capacity of families, their network of contacts, and the potential resources put in place by this network, especially in the case in which parents have an important COVID-19 clinical symptomatology and cannot be present in NICU.

 

A letter from an Italian milk bank describes its experience with milk donation procedures. The milk is collected by the donors at their home and stored in sterile disposable plastic containers inside the freezer compartment of the home refrigerator. Once a week, a hospital driver gathers the milk through doorstep collection, without entering the donor residence, and using protective devices. The article describes the disinfection procedures of the containers and how to use donated milk safely, also including an estimate of the costs [25].

 

The UK Royal Colleges corroborate their indications of April 17 [26], while the WHO on April 28 provided a new version of the Frequently Asked Questions [27] on breastfeeding and COVID-19 for professionals and health professionals, which completes the guidance of March 13 [28,29]. The WHO reconfirms its favourable position regarding breastfeeding in suspected or confirmed mothers, skin-to-skin contact at birth, and kangaroo mother care. It also confirms the milk expression as the best alternative for infants who cannot be breastfed directly, together with the use of donated human milk and formula. For mothers who have stopped breastfeeding, it is always possible to resume at any time. The document reports the key messages for mothers who wish to breastfeed but are afraid of transmitting the virus to their child, as an integral part of a counselling intervention aimed at women and families:

  • The virus has not been detected in the breast milk of suspected or confirmed mothers and, to date, there is no evidence of its transmission with breastfeeding.
  • Infants and young children are at low risk of COVID-19 infection. Of the few confirmed cases in young children, most only had mild or asymptomatic disease.
  • Breastfeeding and skin-to-skin contact significantly reduce the risk of death in infants and young children and have immediate and lasting benefits for the health and development of the baby. In addition, breastfeeding reduces the risk of breast and ovarian cancer for the mother.
  • The numerous benefits of breastfeeding substantially outweigh the potential transmission and disease risks associated with COVID-19.

 

In a letter addressed to Stella Kyriakides [30], European Commissioner for Health and Food Safety, 62 Members of the European Parliament express their concern about the negative consequences that the management of the COVID-19 emergency can have for pregnancy and birth care, in case it is not supported by scientific evidence. Among the measures brought to the attention of the Commissioner, there is the weakening of maternity services, in terms of staff and resources; in some cases, the closure of territorial services, communities and birth centers without due notice; the use not always motivated by obstetric indications of inductions of labor and scheduled caesarean sections; mother-newborns’ separation; denial of the right of women to be accompanied by a person of their choice during labor and delivery, as well as visitors. The proposals suggested by the petitioners include the allocation of adequate resources to maternity services, including personal protective equipment, the adoption of policies aimed to guarantee the presence of a person chosen by the woman during labor and delivery, in line with WHO recommendations, the strengthening of services for taking care of extra-hospital birth and the promotion of evidence-based policies.

 

Following the requests received, the Scientific Societies SIGO, AOGOI, AGUI, SIN, together with FNOPO, prepared the document “Pregnancy and childbirth in the COVID-19 period: practical advice” to promote correct management of care paths considering the needs of mothers, fathers, and children and protecting everyone's safety [31].

 

References
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Publication date: 30 April 2020

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