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Epidemiology for public health
Istituto Superiore di Sanitŕ

 

Epidemiology for public health - ISS

COVID-19: pregnancy, delivery and breastfeeding - April 9th 2020

The main international agencies, the World Health Organization, the CDC and the UK Royal Colleges, regularly issue interim guidance on pregnancy, childbirth, and breastfeeding during the pandemic. The most relevant indications for health care professionals will be presented in a synopsis, currently in progress.

 

The Italian Ministry of Health issued the circular 11257 of 03.31.2020, which contains the main indications related to maternity care [1].

 

Among the international literature, the International Federation of Gynaecology and Obstetrics (FIGO) has published an interim guidance [2] on COVID-19 infection in pregnancy and puerperium. The contents of the guide are addressed to organizations and healthcare professionals globally, and refer to what is recommended by the main international health agencies that deal with the theme of the SARS-CoV-2 epidemic in pregnancy. The document presents several chapters, accompanied by algorithms that summarize the organizational and care modalities in the outpatient setting, in obstetric triage, during intrapartum care of women with confirmed or suspected COVID-19 infection and during assistance to the puerperium and the newborn. A chapter of the guide is entirely focused on the evidence available for the medical treatment of COVID-19 positive women. Other topics addressed in the guide concern the psychological aspects of the pandemic and prevention of the infection transmission to health professionals.

 

The contributions regarding the reorganization of the community and hospital maternity care network during the COVID-19 epidemic is increasing. A recent narrative revision [3] proposes “organizational advice” based on the available evidence and the field experiences gathered, in order to facilitate the reorganization of the maternity units to deal with emergency. The document, accompanied by algorithms and synopsis, aims to promote the care management of pregnancy, childbirth, postpartum, and newborns also including the territorial level and the necessary pre-triage actions.

 

One study [4] describes the results of 10 vaginal swabs collected with RT-PCR in postmenopausal positive COVID patients diagnosed with interstitial pneumonia. All swabs tested negative for SARS-CoV-2 virus. The authors speculate that, for this reason, the risk of vertical transmission during vaginal birth may be very low.

 

As for the risk of COVID-19 vertical transmission during pregnancy from positive mothers to their newborns, a review [5] of data until March 4, 2020 has identified 31 cases. Among these, the absence of the infection was highlighted both in infants and in placentas assessed through histopathological examination.

 

To celebrate the World Health Day 2020, on April 7, the multidisciplinary network of researchers and professionals who deal with mental health in the perinatal period - COST Action Riseup-PPD - funded by the European Union, underlines the importance [6] of increasing the awareness on the impact that COVID-19 can have on maternal mental health.

 

In its recent Initial Guidance, the American Academy of Pediatrics (AAP) resumes the CDC recommendations [7,8,9], stressing that, however difficult, the temporary separation of mother and newborn minimizes the risk of post-natal infection from maternal respiratory secretions. This benefit would be greater in mothers with severe clinical conditions. In any case, the expected benefits of temporary separation should be discussed with the mother prior to delivery. The same indications emerge from the FIGO Global Interim Guidance [2].

 

The AAP indicates to wash the newborn as soon as possible after birth “to remove the viruses potentially present on the skin surface” [7] On this aspect, the indications are conflicting. The UK Royal Colleges indicate “to clean and dry the baby as usual, while the umbilical cord is still intact”. They also recommend, in the absence of other complications, delayed cord clamping [10].

Related to the early washing of the newborn, Baud suggested delayed cord clamping and non-removal of vernix caseosa up to 24 hours after birth [11]. About the hygiene rules for the prevention of the contagion between the mother and the infant, the rooming in, and breast milk expression, the AAP reports the CDC indications. For COVID-19 positive mothers, once back home, AAP recommends keeping the distance of about 2 meters from the baby for as long as possible; when the mother is in closer proximity and for newborn care, she should use a mask and wash her hands thoroughly. These precautionary measures should continue until the mother a) has been afebrile for 72 hours without use of antipyretics and b) at least 7 days have passed since symptoms first appeared, or c) she has negative results from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart. Other caregivers living in the same home who remain under observation for the development of COVID-19, should use standard procedural masks and hand hygiene when within 6 feet of the newborn, until their status is resolved [7].

 

The Public Health Agency of Canada has released advice for mothers on coronavirus disease during pregnancy, childbirth and for the newborn care. The current absence of evidence on vertical transmission during the third trimester of pregnancy and childbirth is indicated. With regard to the policy of reducing visits to hospitals and birth centers, the document indicates that the support person chosen by the woman should not be considered as a visitor. For women who have planned a home birth, the indication is to check whether home birth service and the conditions necessary to ensure a safe environment are still available in their area. Women with suspected, probable or confirmed COVID-19 infection, if they wish, can stay with their baby in the same room, especially during the breastfeeding initiation. During isolation at home, it is important to practice the safety distance with the other family members, except for the newborn. All hygiene measures (hand washing, use of masks, surface disinfection) must be respected. Mothers with a clinical situation that does not allow direct breastfeeding are encouraged to use formula or expressed milk, ask an uninfected adult to feed the baby, sterilize milk pumps and other equipment before each use and do not share feeding bottles or breast pump [12].

 

The indications of the Italian Neonatology Society, supported by the Union of European Neonatal & Perinatal Societies, have been updated and reported in an article by Davanzo et al. The article describes the indications of the main international agencies, and highlights the risks of mother-child separation, suggesting that is should be limited only in cases in which the mother affected by COVID-19 is unable to take care of her newborn, and indicating the use of expressed breast milk given fresh to the baby in cases where direct breastfeeding is not possible [13].

 

Some authors draw attention on the risks related to the systematic separation of mothers and newborns, in particular because of the interference on their relationship and breastfeeding initiation [14,15]. Furlow [15] also underlines that limiting the visits to NICUs to reduce the risk of virus transmission, could cause the reduction of the opportunities for skin-to-skin contact and bonding with newborns.

 

In the reported cases of positive newborns, they tested positive several days after birth had mild symptoms and a good prognosis [16,17,18]. Other reported cases of newborns born from a positive COVID-19 mother were found to be healthy, as the presence of the virus or clinical symptoms were not found [19,20,21]. In one case, both parents were infected and the newborn was found to be healthy, but it was not specified whether the swab was collected or not [22]22. Vertical transmission continues to be undocumented in biological samples [23,18]. The detection for the virus in breast milk is still negative [20,18].

 

Marinelli presents a review on the safe use of containers for expressed human milk and on the treatment of contaminated surfaces [24].

 

References
  1. Ministero della Salute, Direzione Generale della Prevenzione Sanitaria, Direzione Generale della Programmazione Sanitaria & Direzione Generale per l’Igiene e la Sicurezza degli ambienti e la Nutrizione. COVID-19: indicazioni per gravida-partoriente, puerpera, neonato e allattamento. (2020).
  2. Poon LC, Yang H, Kapur A, Melamed N, Dao B, Divakar H, David McIntyre H, Kihara AB, Ayres-de-Campos D, Ferrazzi EM, Carlo Di Renzo G, Hod M. Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: Information for healthcare professionals. Int J Gynaecol Obstet. 2020 Apr 4. doi: 10.1002/ijgo.13156. [Epub ahead of print] PubMed PMID: 32248521.
  3. Capanna F, Haydar A, McCarey C, Bernini Carri E, Bartha Rasero J, Tsibizova V, Helmer H, Makatsarya A, Di Renzo GC. Preparing an Obstetric Unit in the Heart of the Epidemic Strike of COVID-19: Quick Reorganization Tips. J Matern Fetal Neonatal Med, 1-11 2020 Mar 29[Online ahead of print] PMID: 32223490 DOI: 10.1080/14767058.2020.1749258
  4. Qiu L, Liu X, Xiao M, Xie J, Cao W, Liu Z, Morse A, Xie Y, Li T, Zhu L. SARS-CoV-2 is not detectable in the vaginal fluid of women with severe COVID-19 infection. Clin Infect Dis. 2020 Apr 2. pii: ciaa375. doi: 10.1093/cid/ciaa375. [Epub ahead of print] PubMed PMID: 32241022.
  5. Karimi-Zarchi M, Neamatzadeh H, Dastgheib SA, Abbasi H, Mirjalili SR, Behforouz A, Ferdosian F, Bahrami R. Vertical Transmission of Coronavirus Disease 19 (COVID-19) from Infected Pregnant Mothers to Neonates: A Review. Fetal Pediatr Pathol. 2020 Apr 2:1-5. doi: 10.1080/15513815.2020.1747120. [Epub ahead of print] PubMed PMID: 32238084.
  6. COST Action Riseup-PPD. Statement World Health Day 2020: Research is needed to better understand the impact of COVID19 on maternal mental health. Disponibile online (https://drive.google.com/file/d/1YSsZY4tvVZ8X8vSNVUGo6thPaPLU1qj2/view, ultimo accesso 08 aprile 2020)
  7. Puopolo, K., Hudak, M., Kimberlin, D. & Cummings, J. American Academy of Pediatrics Committee. INITIAL GUIDANCE: Management of Infants Born to Mothers with COVID-19 Date of Document: April 2, 2020. (2020).
  8. CDCa, 2020.
  9. CDCb, 2020.
  10. 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 Friday 3 April 2020.
  11. Baud, D. et al. Correspondence COVID-19 in pregnant. Lancet Infect. Dis. 3099, 30192 (2020).
  12. Public Health Agency of Canada. CORONAVIRUS DISEASE (COVID-19) PREGNANCY , CHILDBIRTH AND CARING FOR NEWBORNS : ON COVID-19 AND FOR MORE INFORMATION. (2020).
  13. Davanzo, R. et al. Breastfeeding and Coronavirus Disease-2019. Ad interim indications of the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies. Matern. Child Nutr. e13010 (2020). doi:10.1111/mcn.13010
  14. Davanzo, R. Breast feeding at the time of COVID-19: do not forget expressed mother’s milk, please. Arch Dis Child Fetal Neonatal Ed. 2020 Apr 6. pii: fetalneonatal-2020-319149. doi: 10.1136/archdischild-2020-319149.
  15. Furlow, B. US NICUs and donor milk banks brace for COVID-19. Lancet Child Adolesc. Heal. 4642, 30103 (2020).
  16. Kamali Aghdam, M., Jafari, N. & Eftekhari, K. Novel coronavirus in a 15-day-old neonate with clinical signs of sepsis, a case report. Infect. Dis. (London, England) 0, 1–3 (2020).
  17. Alonso Díaz, C., López Maestro, M., Moral Pumarega, M. T., Flores Antón, B. & Pallás Alonso, C. Primer caso de infección neonatal por SARS-CoV-2 en España. An. Pediatría 2–3 (2020). doi:10.1016/j.anpedi.2020.03.002
  18. Panahi, L., Amiri, M. & Pouy, S. Risks of Novel Coronavirus Disease (COVID-19) in Pregnancy; a Narrative Review. Arch. Acad. Emerg. Med. 8, e34 (2020).
  19. Gidlöf, S., Savchenko, J., Brune, T. & Josefsson, H. COVID-19 in pregnancy with comorbidities: More liberal testing strategy is needed. Acta Obstet. Gynecol. Scand. 0–2 (2020). doi:10.1111/aogs.13862
  20. Kalafat, E. et al. Lung ultrasound and computed tomographic findings in pregnant woman with COVID-19. Ultrasound Obstet. Gynecol. (2020). doi:10.1002/uog.22034
  21. Khan, S. et al. Impact of COVID-19 infection on pregnancy outcomes and the risk of maternal-to-neonatal intrapartum transmission of COVID-19 during natural birth. Infect. Control Hosp. Epidemiol. (2020). doi:10.1017/ice.2020.84
  22. Iqbal, S. N. et al. An Uncomplicated Delivery in a Patient with Covid-19 in the United States. N. Engl. J. Med. 1–3 (2020). doi:10.1056/NEJMc2007605
  23. Dong Hwan, L. et al. Emergency cesarean section performed in a patient with confirmed severe acute respiratory syndrome Coronavirus-2: A case report. Korean J. Anesthesiol. (2020).
  24. Marinelli, K. A. & Lawrence, R. M. Safe Handling of Containers of Expressed Human Milk in all Settings During the CoV-2 (COVID-19) Pandemic. 00, 1-4 (2020).

 

Resources

 

Publication date: 20 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