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Epidemiology for public health
Istituto Superiore di Sanità

 

Epidemiology for public health - ISS

COVID-19: pregnancy, delivery and breastfeeding - March 5th 2020

The Italian scientific community of neonatologists, paediatricians, gynaecologists, obstetricians and midwives (SIN, SIMP, SIP, ACP, SIGO, AOGOI, AGUI, SIAARTI and FNOPO) has joined the group established by Italian National Institute of Health (ISS) and coordinated by the National Centre for Disease Prevention and Health Promotion (CNaPPS). The main aim is to collect, assess and disseminate scientific literature updates on Covid-19 in pregnancy, childbirth and breastfeeding.

 

The aim of the initiative is to provide indications for clinical practice intended for health professionals who take care of pregnancies, childbirth and breastfeeding/infant feeding in the Country. The plan is to disseminate each update through ISS’s Epidemiology website EpiCentro, where last week a short document on the topic was already published.

 

The CNaPPS has assumed responsibility to run daily a query against PubMed, Scopus, Embase, and CINAHL databases to search the most recent and accessible literature on the topic. No limits have been set for the study design or language of publication, while the start date has been fixed from January 2000 on. The results yielded from the search on Covid-19 in pregnant women, childbirth and puerperium have been put together with other documents from international governmental agencies, or scientific societies.

 

Also, to date, no indication related to Covid-19 in pregnancy, childbirth and breastfeeding has been found through the research performed on the official websites of the Ministry of Health and Public Health Institutes of the affected Countries.

 

From the literature review of the last week, the following updates are reported:

  • A Chinese publication [1] describes the clinical features and histopathological examination of the placenta in 3 pregnant women with new Coronavirus infection, who delivered through caesarean section. The women, who had contracted the infection in the third trimester of pregnancy, were feverish without significant leukopenia and lymphopenia, one of them had developed viral pneumonia. The swabs for virus investigation were negative in the three newborns, and no vertical maternal-foetal transmission of the infection was detected. The histopathological examination of the placenta did not identify morphological changes related to the viral infection, and the investigation of the virus in the placental tissues was negative. The authors recommend an anatomopathological examination of the placenta and any abortion material in pregnant women with Covid-19 infection.
  • Several trials on the use of mesenchymal stem cells, derived from the umbilical cord blood of the newborn for the treatment of SARS-CoV-2 pneumonia, are underway. The first data are expected shortly [2]. There are also ongoing studies on the use of respiratory antiviral drugs in breastfeeding mothers [3].
  • The indications on clinical behaviour provided by the CDC, already summarised in the document published on EpiCentro, remain unchanged [4,5,6]. Considering the limited evidence currently available, the opinions on direct breastfeeding are not unique. The CDC position is oriented to protect the mother-newborn relationship respecting strict hygiene standards, and using expressed breast milk if safe mother-baby contact is not possible. The indications are based on the available evidence, showing no documented cases or biological plausibility of vertical transmission between mother and baby or through breast milk, in the present SARS-COV-2 or the previous SARS and MERS epidemics [7]. Instead, some Chinese authors suggest interrupting breastfeeding without referring to the use of expressed breast milk [8,9]. Favre et al., in a correspondence published in Lancet, suggest the temporary isolation of the newborn and not direct breastfeeding in SARS-CoV-2 positive mothers [10].

The clinical, organizational and logistical management of mothers and infants represents a challenge for health services already overloaded with emergency management. Moreover, different institutions and authors seem to apply the precautionary principle differently, in light of the same limited evidence. Whenever possible, it is essential to preserve the physiology of childbirth, the mother-child relationship and breastfeeding that, even in uncertainty, guarantee a protective potential for the newborn, widely documented in the literature, including previous SARS or MERS epidemics.

 

In this state of uncertainty, providing convincing and undisputable recommendations for SARS-COV-2 positive mothers and/or for those with Covid-19 clinical symptoms is challenging. Therefore, a multidisciplinary case-by-case assessment is desirable and recommended. Notably, the best care approach can be reached by taking into account the maternal exposure time to the coronavirus, the gestational age, the ongoing treatment, the individual immune response situation and all the variables that can influence the clinical condition.

 

References:
  1. Zhonghua Bing Li Xue Za Zhi. 2020 Mar 1;49(0):E005. doi: 10.3760/cma.j.cn112151-20200225-00138. Online ahead of print.[Pregnant women with new coronavirus infection: a clinical characteristics and placental pathological analysis of three cases].
  2. http://apps.who.int/trialsearch/
  3. Anderson, P. O. (2020). Breastfeeding and Respiratory Antivirals: Coronavirus and Influenza. Breastfeeding Medicine, bfm.2020.29149.poa.
  4. CDC. Frequently Asked Questions and Answers: Coronavirus Disease 2019 (COVID-19) and Pregnancy [Internet]. [cited 2020 Feb 25]. .
  5. CDC. Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings. Retrieved February 25, 2020
  6. CDC. Interim Guidance on Breastfeeding for a Mother Confirmed or Under Investigation For COVID-19 [Internet]. [cited 2020 Feb 25].
  7. Schwartz DA, Graham AL. Potential Maternal and Infant Outcomes from (Wuhan) Coronavirus 2019-nCoV Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Coronavirus Infections. Viruses. 2020;12(2):E194. Published 2020 Feb 10. doi:10.3390/v12020194
  8. 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.
  9. Qiao, J. (2020). Comment What are the risks of COVID-19 infection in pregnant women?
  10. Guillaume Favre, LĂ©o Pomar, Xiaolong Qi, Karin Nielsen-Saines, Didier Musso, David Baud. Guidelines for pregnant women with suspected SARS-CoV-2 infection. Correspondence.

 

Resources

 

Publication date: March 16, 2020

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