Q. I am pregnant. What are my chances of having CoViD infection?
Pregnant women are at SIMILAR risk of infection and hospitalizations as non- pregnant women. They are at no greater risk of becoming seriously unwell than other healthy adults.
However, if someone has a high risk pregnancy, specially heart disease (both congenital and acquired), or asthma or other lung diseases, they have been categorized as extremely vulnerable and at increased risk of poor outcomes if infected with CoViD-19. Other pre-existing medical problems include such as high blood pressure and diabetes, or obesity. Third trimester, i.e.28 weeks onwards is the riskiest period.
Q. Is my baby at risk if I have CoViD-19 infection?
A. Studies conducted uptil now DONOT show any increased risk of miscarriage or teratogenicity (i.e. malformations) in babies born to mothers with CoViD-19 infection.
vertical transmission (mother to baby in uterus) is probable, but less likely. There is theoretical risk of having growth restriction in fetus due to thrombogenic nature of infection, however no studies have evidence in favor of it.
PART 2 - PRECAUTIONS:
Most important thing is –‘SOCIAL DISTANCING’
Q. What precautions should I take to avoid CoViD-19 infection?
A. Avoid unnecessary visits outside your home, and if it is necessary • Do maintain a distance of more than 5 ft from others • Wash your hands regularly • Use a tissue when you or anyone near you coughs or sneezes, DISCARD IT and wash your hands • Avoid contact with probable CoViD-19 cases (these symptoms include high temperature and/or new and continuous cough) • Avoid public transport • Avoid gatherings in enclosed space • Limit the hospital visit to doctors. Use telemedicine first, and still if needed, visit doctor after booking appointment. Limit your stay in the hospital or waiting areas.
Q. My doctor is asking me to minimize hospital visits. What should I do?
A. limit hospital visits to minimum. Go for teleconsultation, where physical examination is not necessary . This will prevent you from acquiring CoViD-19 infection from fellow patients and healthcare workers. Also, the quality care can be diverted to in-patients and emergencies • IMP-When visiting your doctor, do try for getting all the investigations and scans in a single visit • if you have problems such as cramping, pain abdomen, bleeding, discharge, leaking or reduction in fetal movements, visit your doctor
Q. Is Facemask necessary?
A. Yes, facemask (three‐ply surgical mask) is a must to prevent infection to you and others, along with following other norms of social distancing and hand hygiene.
PART 3 PREGNANCY SPECIFIC QUERIES
Q. I am pregnant and I have fever. What should I do next?
CoViD-19 is one of the causes of fever. However, you need to get investigated for rest other causes as well, for eg. Urinary tract infection, sore throat, bacterial infections, water breaking, including CoViD-19.
Q. When do I suspect that I have CoViD-19 infection?
A. If you have had contact with a suspected or confirmed CoViD patient, or if you develop
• High temperature or
• New, continuous cough, Sore throat or Shortness of breath
• Chills, Shaking with chills, Muscle pain
• A loss or change to your sense of smell or taste.
Q. Which tests are done for CoViD-19 infection?
A. Currently, the test involves swabs being taken from your mouth and nose. You may also be asked to cough up sputum, which is a mixture of saliva and mucus.
Usually, it takes 24–48 hours for the result to be available. Meanwhile, in hospital you may be considered as potentially infectious until the results are negative.
The results are also coming out to be falsely negative. So. If you have probable symptoms, but the results are negative, one still needs to continue the precautions and send the repeat sample if needed.
If you have symptoms of coronavirus but have recently received a negative test result, your maternity team may still use caution when caring for you. Sometimes, repeat testing might be needed.
DURING LABOR and DELIVERY
Q. Will I be tested for CoViD-19 infection at the time of Labor pains and Delivery?
A. CoViD-19 testing strategies have been individualized by medical institutions. Usually, the sample is sent for testing once you admit to hospital and till the results come out to be negative, you are treated as being CoViD positive and necessary precautions are taken by healthcare providers, like face-masks and PPE kits.
Q.How many visits are hospital visits after delivery of the baby?
A. Your postnatal care will be individualized to meet your needs and those of your baby. However, once in hospital, do ensure that both evaluation and vaccination are done is same visit.
For CoViD Positive Patients
Q. My CoViD report is positive. What should I do?
A. First of all, notify the case to your healthcare practitioner. It is better to first inform them and then accordingly visit the doctor once adequate precautions have been arranged by them. CoViD-19 infection is a notifiable disease, and contact tracing will follow.
If you have no symptoms or mild symptoms, you will be evaluated and might be advised to recover at home and go for self-isolation. If however, you are symptomatic or need extra care, you will be treated in hospital.
Q. Will I have a premature Delivery if I am CoViD positive?
A. Some reports have suggested that some babies have been born prematurely to women who were very unwell with coronavirus. However, there are chances of this being iatrogenic for the benefit of the women’s health and to enable them to recover. Importantly, babies born to COVID positive mothers do not have extra risk of NICU admission, compared to non-infected mother.
Q. How will I be managed?
A. • Asymptomatic or Mild symptoms - fluid and electrolyte balance, symptomatic treatment, and surveillance is the same as for suspected/probable cases. There is no proven antiviral treatment till now for CoViD-19. However, a battery of drugs from other categories like antimalarials, antiretrovirals, blood thinners will be used according to severity and progress of your symptoms you will be monitored for other bacterial infection and fetal surveillance with continuous electronic fetal monitoring will be done during labor.
• Chest CT scanning has a high sensitivity for diagnosis of COVID‐19. In a pregnant woman, a chest CT scan may be considered a radiation shield applied over the gravid uterus.
• Severe cases – have to be managed according to current guidelines • Monitoring for bacterial infection (blood culture, midstream or catheterized specimen urine microscopy and culture) should be done, with timely use of appropriate antibiotics when there is evidence of secondary bacterial infection • Fetal surveillance: undertake CTG for FHR monitoring when gestational age is beyond the limit of viability based on local practice (23–28 weeks)
Q. What is self- isolation?
A. You along with the people who are living with you have to stay indoors for 14 days, to avoid spreading the infection outside the home.
• Not go to school, work, or public areas • Not use public transport • Stay at home and do not allow visitors • Open windows to ventilate rooms • Separate yourself from other members of the household as far as possible. Encourage separate towels, crockery and utensils and eating at different times • Use friends, family or delivery services to provide ration, but ask them to leave it outside your doors.
Q. What about my medical appointments during self- isolation?
Prefer video calling the doctor. Visit them only if necessary after discussing with them.
Q. I am in my third trimester and CoViD positive. Does that mean I need to undergo Labour induction?
A. For women with suspected or confirmed COVID-19 in the third trimester, it is reasonable to attempt to postpone delivery (if no other medical indications arise) until a negative test result is obtained or quarantine restrictions are lifted in an attempt to avoid virus transmission to the neonate.
COVID‐19 infection itself is not an indication for delivery, unless there is a need to improve maternal oxygenation. For suspected/probable/confirmed cases of COVID‐19 infection, delivery should ideally be conducted in a negative pressure isolation room.
DURING LABOUR and AFTER DELIVERY
Q. What happens if I go in labour during CoViD infection?
If you are asymptomatic, currently there is no evidence to suggest you cannot give birth vaginally or that you would be safer having a caesarean birth so your birth choices should be respected. Your baby will be monitored using continuous electronic fetal monitoring, and your oxygen levels can be monitored hourly. In case you are not able to push during 2nd stage, or get exhausted, instrumental delivery will be offered.
There should be a low threshold to expedite the delivery when there is fetal distress, poor progress in labor, and/or deterioration in maternal condition.
In severely symptomatic, septic cases, those in failure, or any other obstetrical indication, caesarean section will be done.
Q. What are the risks to my baby?
Studies report a small number of babies to be diagnosed with coronavirus shortly after birth. It is not certain whether transmission was before or soon after birth. Vertical transmission, i.e. infection transmission in womb, or during labour is rare. However, the close contact with mother, specially after birth is most risky.
Baby born to CoViD positive mother is considered positive unless reports are negative. However, testing baby is according to individual institute policy.
If the neonate tests positive for SARS-CoV-2, separation is not necessary.
Q. Will I be able to breastfeed my baby?
There is no evidence showing that the virus can be carried or passed on in breastmilk. Nevertheless, it’s the close contact during breastfeeding which may pass virus. So, its better to express the milk and fed to baby by a healthy contact. Make sure to wash your hands before touching any breast pump or bottle parts and clean all pump and bottle parts after use Till then, its keep baby separated unless mother is negative. It's better to have a discussion about the risks and benefits of breastfeeding between you and your family and your maternity team.
The concept of ‘Rooming-in’ can also be followed, but then strict adherence to social distancing and hand hygiene need to be followed. Baby can be brought near mother only at the time of feeding. Mother has to practice hand hygiene before feeding and also wear a protective mask throughout the process of feeding. Rest of the times, a plastic curtain can be used around baby cot to minimize transmission to baby. This guidance may change as knowledge evolves.
CoViD19 and ABORTION
Q. I am 6 weeks pregnant and CoViD positive. Do I need to abort?
Studies are ongoing regarding effects of CoViD infection in pregnancy. No reports suggest teratogenicity till now. However, there is theoretical risk of harmful effects of hyperthermia due to CoViD infection. Nevertheless, it is not indication for abortion.
One must have a case to case-based discussion between you and your maternity team.
• Miscarried embryos/fetuses and placentae of COVID‐19‐infected pregnant women should be treated as infectious tissues and they should be disposed of appropriately; if possible, testing of these tissues for SARS‐CoV‐2 by qRT‐PCR should be undertaken.
Post CoVid Recovery
Q. What happens to me after I have recovered from CoViD infection ?
A. Once you have recovered, an ultrasound scan will be arranged at least 2 weeks after your recovery, to check baby’s growth and other parameters.
Q. I think I am having anxiety. How to know and what to do?
A. The following indicate that you need professional help with regard to anxiety and depression.
• Feeling sad, hopeless, worthless, or helpless • Having fear or worry, which may cause a fast heartbeat • Feeling that life is not worth living • Having repeated, scary, and unwanted thoughts that are hard to get rid of
There also are treatment and support resources you can access over the phone or online. Talk with your ob-gyn or other health care professional about how to get help if you’re having symptoms. Reaching out to friends and family during this time may help. Phone calls, texts, and online chats are safe ways to stay connected.
Protecting the Newborn !
Q. Does my newborn need to wear mask?
A. Follow advice as given above in breastfeeding section. Masks and Plastic face shields for newborns and infants are NOT recommended. An infant face shield could increase the risk of Sudden Infant Death Syndrome (SIDS) or accidental suffocation and strangulation. CDC recommends that everyone 2 years and older wear a cloth face covering that covers their nose and mouth when they are out in the community. Because of the danger of suffocation, do NOT put cloth face coverings on babies or children younger than 2 years. In fact, Cloth face coverings should also NOT be worn by anyone who has trouble breathing, is unconscious, can’t move, or is otherwise unable to remove the face covering without assistance.
Q. When can I hold my Baby without worries?
A. Three days after recovery(i.e. negative test + resolution of fever without the use of fever-reducing medications plus improvement in respiratory symptoms)
For mothers with laboratory-confirmed COVID-19 who have never been symptomatic, transmission precautions can be discontinued when at least 10 days have passed since the date of their first positive COVID-19 diagnostic test
FOR HEALTHCARE PROVIDERS
• Routine prenatal care in uninfected women
• Care should be different for low- risk versus high-risk patients (eg, multiple gestation, hypertension, diabetes, twins, etc.)
• Focus should be on telehealth, reducing the number of in-person visits without compromising mother and baby’s health, timing of visits, grouping tests for the same visit/day (eg, aneuploidy, diabetes, infection screening)
• Minimum timing of indicated obstetric ultrasound examinations (eg, gestational age, fetal anomaly, fetal growth, placental attachment), and timing and frequency of use of nonstress tests and biophysical profiles.
• Development of fetal growth restriction is a theoretical concern and has been described with other SARS infections, which should be taken care of. Placental insufficiency is plausible because maternal COVID-19 has been associated with uteroplacental vascular malperfusion. However, very limited COVID-19-specific data on fetal growth are available
The infants of mothers with COVID-19 are considered COVID-19 suspects, and they should be tested, isolated from other healthy infants, and cared for accordingly. FIGO says, where testing capacity is available, neonates should be tested for SARS-CoV-2 infection as soon as possible and within the first 24 hours of age using available molecular assays. Repeat testing should be performed at approximately 48 hours of age if the infant is still at the birth facility
Guidance for Management of Pregnant Women
in COVID-19 Pandemic, Indian Council of Medical Research (ICMR)
Coronavirus infection and pregnancy, Royal College of Obstetrics and Gynaecology (RCOG)
COVID-19 Early Pregnancy Guidance, International Federation of Gynaecology and Obstetrics (FIGO consensus)
Novel Coronavirus 2019 (COVID-19), American College of Obstetrics and Gynaecology (ACOG)