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\begin{document}

\title{COVID-19 in Pregnancy- A comprehensive summary of current guidelines}



\author[1]{Kavita Narang}%
\author[1]{Eniola Ibirogba}%
\author[1]{Amro Elrefaei}%
\author[1]{Ayssa Teles Abrao Trad}%
\author[1]{Regan Theiler}%
\author[2]{Olivier Picone}%
\author[3]{Mark Kilby}%
\author[4]{Ramon Escuriet}%
\author[5]{Anna Suy}%
\author[5]{Elena Carreras}%
\author[6]{Gabriele Tonnie}%
\author[1]{Rodrigo Ruano}%
\affil[1]{Mayo Clinic}%
\affil[2]{Hôpital Louis-Mourier}%
\affil[3]{Birmingham university}%
\affil[4]{CatSalut}%
\affil[5]{Hospital Universitari Vall d'Hebron}%
\affil[6]{Emilia-Romagna Region}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\begin{abstract}
Background: Since the declaration of the global pandemic of COVID-19 by
the World Health Organization on March 11, 2020; we have continued to
see a steady rise in the numbers of people infected by SARS-CoV-2.
However, there is still very limited data on the course and outcomes of
this serious infection in a vulnerable population of pregnant patients
and their fetuses. International perinatal societies and institutions
including SMFM, ACOG, RCOG, ISUOG, CDC, CNGOF, ISS/SIEOG and CatSalut
have released guidelines for the care of these patients. Objectives: We
aim to summarize these current guidelines in a comprehensive review for
patients, healthcare workers and healthcare institutions. Search
Strategy: A literature search was performed through PubMed, and direct
review of professional society's website and journal publications. A
total of 15 papers were identified from 10 societies and reviewed by two
authors who were in agreement. Selection Criteria: The most updated
guideline including information on antepartum, intrapartum and
postpartum care put forth by each society was included. Data Collection
and Analysis: Data specific to antepartum, intrapartum, and postpartum
were abstracted from the publications and summarized into tables 2, 3
and 4 respectively. Main Results: The summary of guidelines for
management of COVID-19 in pregnancy across different perinatal societies
is consistent, with some variation in the strength of recommendations.
Conclusions: It is important to recognize that these guidelines are
frequently updated, as we continue to learn more about the course and
impact of COVID-19 in pregnancy. The references to access all these
guidelines are provided.%
\end{abstract}%



\sloppy


Tweetable Abstract

Since the declaration of the global pandemic of COVID-19 by the World
Health Organization on March 11, 2020; we have continued to see a steady
rise in the numbers of people infected by SARS-CoV-2. However, there is
still very limited data on the course and outcomes of this serious
infection in a vulnerable population of pregnant patients and their
fetuses. International perinatal societies and institutions including
SMFM, ACOG, RCOG, ISUOG, CDC, CNGOF, ISS/SIEOG and CatSalut have
released guidelines for the care of these patients. The objective of
this paper is to summarize these current guidelines in a comprehensive
review for patients, healthcare workers and healthcare institutions.

Introduction

The World Health Organization (WHO) declared a global pandemic of
COVID-19, caused by SARS-CoV-2 on March 11,
2020\textsuperscript{{[}1{]}}. The rapidly escalating numbers of
individuals infected globally remain on the rise and little is still
known about the course and outcomes of this serious infection in a
vulnerable population of pregnant patients and their fetuses.

Professional societies and institutions involved in the care of pregnant
patients, including Society for Maternal and Fetal Medicine
(SMFM)\textsuperscript{{[}2, 3{]}} from United States, American College
of Obstetrics and Gynecology (ACOG)\textsuperscript{{[}4, 5{]}} from
United States, Royal College of Obstetrics and Gynecology
(RCOG)\textsuperscript{{[}6{]}} from United Kingdom, International
Society for Ultrasound in Obstetrics and Gynecology
(ISUOG)\textsuperscript{{[}7{]}}, United States Centers of disease
control (CDC)\textsuperscript{{[}8, 9{]}}, the World Health Organization
(WHO)\textsuperscript{{[}10{]}}, College National de Gynecologie et
Obstetrique Francais (CNGOF)\textsuperscript{{[}11{]}} from France,
Societ\selectlanguage{ngerman}à Italiana di Ecografia Ostetrico Ginecologica /Istituto Superiore
Sanità (SIEOG/ISS)\textsuperscript{{[}12, 13{]}} from Italy and the
Catalan Health Service (CatSalut)\textsuperscript{{[}14, 15{]}} from
Spain have released independent guidelines for the assessment and care
of pregnant patients from prenatal course to intrapartum to postpartum.

A paper published by Boelig et al in March 2020 to guide Maternal Fetal
Medicine specialists on the care of SARS-Cov-2 pregnant patients, urged
healthcare providers and their institution to develop internal
guidelines to have their unit ready to care for these
patients\textsuperscript{{[}2{]}}.

In order to help institutions keep up with this rapidly evolving
landscape; the authors of this paper aim to summarize and discuss all
the current guidelines put forth by the aforementioned professional
societies and institutions into one document. The primary goal is to
allow institutions access to a comprehensive summary of guidelines
related to the SARS-Cov-2 pandemic in pregnancies; which they can adapt
to their practice environment and capabilities. The primary focus of all
published guidelines is to design a model where patients and their
families, as well as healthcare workers in the frontline of the pandemic
are protected and prepared.

Methods

A literature search was performed through direct review of professional
society's website and journal publications, and PubMed. A total of 15
papers were identified from 10 societies and reviewed by two authors who
were in agreement. Summary of guidelines were retrieved from the sources
described in Table 1, arranged in ascending order of publication date.
(Figure 1)

Data abstracted from these guidelines will include specifics on
antepartum, intrapartum and postpartum management as outlined in the
results tables (Tables 2, 3 and 4).

Results

All the data from the aforementioned publications are summarized Tables
2, 3 and 4.

\emph{Table 2} summarizes prenatal and antepartum care guidelines. All
guidelines support some form of screening of pregnant patients depending
on symptoms and exposure, encourage the use of telehealth for prenatal
visits and limiting face to face visits and ultrasounds only to those
that are medically necessary. The use of antenatal corticosteroids for
fetal lung maturation can be continued till 34 weeks gestation, but the
use of steroids in the late preterm period, \textgreater{} 34 0/7 weeks
gestation remains controversial. All ultrasound equipment and patient
rooms should be appropriately cleaned after each use.

\emph{Table 3} summarizes intrapartum care guidelines. All guidelines
recommend a designated area within the unit to care for COVID-19
positive pregnant patients or Person under investigation (PUI). Timing
and mode of delivery should follow routine obstetric indications.
Cesarean delivery should be reserved for obstetric indications only;
infection with COVID-19 is not an indication for cesarean delivery
unless there is acute decompensation of mother or fetus. Only one
asymptomatic support person is allowed to be there at time of delivery.
Shortening second stage of labor can be considered with the use of
operative delivery or laboring down. Patients and healthcare workers
should be appropriately gowned gloved and have protective face masks;
specifically N95 should be used for aerosol generating procedures such
as forceful expiration during pushing. There is no contraindication to
regional or general anesthesia if indicated; but appropriate PPE use is
encouraged.

Table 4 summarizes postpartum care guidelines. All guidelines encourage
early discharge from the hospital, 1 day for vaginal delivery and 2 days
for cesarean delivery. This limits face to face exposure and increases
bed availability. Separation of mother and baby or discouraging
breastfeeding are not advised, unless the mother is acutely ill.
However, mothers are encouraged to 1) Practice respiratory hygiene
during feeding, 2) wear a mask, 3) Wash hands before and after touching
the baby and, 4) Routinely clean and disinfect surfaces they have
touched. Postpartum visits should be performed over telehealth, unless
face to face visit is essential to management.

Discussion

The overall summary of guidelines for management of COVID-19 in
pregnancy across different professional societies and institutions are
consistent; with some variation in the strength of recommendations.
Global societies such as WHO and CDC have a similar approach to their
guideline publication; keeping the recommendations broad so it can be
utilized across all shapes and sizes of healthcare institutions. Many of
their recommendations overlap with those for the general population and
they provide great resources to guide readers to perinatal societies for
more specific questions.

International perinatal societies including ACOG, RCOG, SMFM, ISUOG,
CNGOF, ISS/SIEOG and public institution CatSalut, all share similar
recommendations answering questions that are very specific to the care
of pregnant patients- from prenatal screening, antepartum care, details
of intrapartum care during different stages of labor in emergency and
non-emergency settings, to postpartum care and follow up. The guidelines
put forth by SMFM (United States) are most specific to the care of high
risk pregnancies; given their expertise in this field. ACOG (United
States) and RCOG (United Kingdom) summarize recommendations that are
suitable for lower risk pregnant patients. CNGOF (France) and ISS/SIEOG
(Italy) and CatSalut (Barcelona), give some practical recommendation for
the management of infected pregnant women. ISUOG (International)
provides more information specific to managing and cleaning ultrasound
equipment--an essential tool in the care of pregnant patients which
could be a vector for disease transmission if sanitization is not a
priority.

The consensus amongst the all perinatal societies encourages all
institutions to transition to telehealth when appropriate and limit the
number of face to face visits. Ultrasounds and antenatal surveillance
should be performed only if medically indicated. The use of antenatal
steroids for fetal lung maturation for patient at high risk of preterm
birth within 7 days should still be performed if pregnancy is between 24
0/7 to 33 6/7 weeks gestation; but should be avoided during late preterm
of 34 0/7 to 36 6/7 weeks gestation. All institutions should set up a
designated screening area, labor and delivery rooms, and operating rooms
for COVID-19 patients. All patients should be screened for symptoms,
travel history, contact history and follow the appropriate algorithm
provided to guide need for performing real time PCR test. As the numbers
of testing sites and resources have increased over the past few weeks,
there should be consideration for screening every pregnant patient being
admitted if feasible. Societies recommend only one consistent support
person to be present during delivery. Mode and timing of delivery should
still be performed on the basis of routine obstetric indications.
Aerosol generating procedures such as use of oxygen and forceful pushing
should be avoided to protect everyone in the delivery room. Appropriate
PPE should be donned by patients and healthcare workers during all
interactions. N95 should be worn during aerosol generating
procedures\textsuperscript{{[}5{]}}. Currently, mother and baby
separation and discouraging breastfeeding are not advised unless the
mother is acutely ill. However, mothers are advised that breast pumping
should be considered over breastfeeding and to wash hands before
handling baby, touching pumps or bottle, avoid coughing while baby is
feeding, consider wearing face mask while feeding or handling baby. If a
breast pump us used, clean properly after each use, and routinely clean
all surfaces that are touched. The length of hospital stay should be
decreased to 1 day for vaginal delivery and 2 days for cesarean delivery
to limit time of exposure for patients and healthcare workers in the
hospital while also increasing bed capacity. Once discharged, patients
are advised to continue social distancing, and routine postpartum visits
can be conducted using telehealth. The method of telehealth should be
individualized based on institution resources and availability.

Conclusion

The present manuscript summarizes the guidelines for Obstetrical and
perinatal managements of pregnant women during the SARS-OcV-2 pandemic,
which can be an overall reference for Obstetricians all over the world.
Many similarities are identified amongst these guidelines. All of the
international professional societies and institutions discussed in this
paper, including ACOG, RCOG, SMFM, ISUOG, WHO, CNGOF, ISS/SIEOG,
CatSalut and CDC, continue to work tirelessly to put forth updated
information for the care of pregnant patients and beyond. This
manuscript also provides the summary of the source for continuous
updates. It is imperative for readers to continue to use the most
updated guidelines available as we continue to learn more about the
impacts of the SARS-Cov-2 pandemic in pregnancy.

\emph{}

\textbf{Acknowledgements:} None

\textbf{Funding:} None

\textbf{Disclosures of Interest:} None of the authors of this paper have
any financial disclosures or conflicts of interest

\textbf{Contribution of Authorship}

Kavita Narang MD- Literature review, manuscript outline and writing

Eniola R. Ibirogba MBBS- Assisted with manuscript writing

Amro Elrefaei MBBCh- Assisted with manuscript writing

Ayssa Teles Abrao Trad MD- Assisted with manuscript writing

Regan Theiler MD PhD - Assisted with manuscript writing

Olivier Picone MD PhD- Assisted with manuscript writing

Mark Kilby MD PhD - Assisted with manuscript writing

Ramón Escuriet PhD- Assisted with manuscript writing

Anna Suy MD PhD- Assisted with manuscript writing

Elena Carreras MD PhD\textsuperscript{-} Assisted with manuscript
writing

Gabriele Toni MD PhD - Assisted with manuscript writing

Rodrigo Ruano MD PhD- Assisted with manuscript writing

\textbf{Details of ethical approval:} Not applicable

References

1. Organization, W.H., \emph{WHO Director-General's opening remarks at
the media briefing on COVID-19.} 2020.

2. Boelig, R.C., et al., \emph{MFM Guidance for COVID-19.} American
Journal of Obstetrics \& Gynecology MFM, 2020: p. 100106.

3. Boelig, R.C., et al., \emph{Labor and Delivery Guidance for
COVID-19.} American Journal of Obstetrics \& Gynecology MFM, 2020: p.
100110.

4. (ACOG), A.C.o.O.a.G., \emph{Novel Coronavirus COVID-19, a practice
advisory.} 2020.

5. Gynecology, A.C.o.O.a., \emph{COVID-19 FAQs for
Obstetrician-Gynecologists, Obstetrics.}

6. (RCOG), R.C.o.O.a.G., \emph{Coronavirus (COVID-19) infection in
pregnancy: information for healthcare professionals.} 2020(Version 3).

7. Poon, L.C., et al., \emph{ISUOG Interim Guidance on 2019 novel
coronavirus infection during pregnancy and puerperium: information for
healthcare professionals.} Ultrasound in Obstetrics \&
Gynecology.\textbf{n/a} (n/a).

8. Control, C.f.D., \emph{Information for Healthcare Providers: COVID-19
and Pregnant Women.} 2020.

9. Control, C.f.D., \emph{Pregnany and Breastfeeding.} 2020.

10. Organization, W.H., \emph{Q\&A on COVID-19, pregnancy, childbirth
and breastfeeding.} 2020.

11. Peyronnet, V., et al., \emph{Infection par le SARS-CoV-2~chez les
femmes enceintes~: état des connaissances et proposition de prise en
charge par CNGOF.} Gynécologie Obstétrique Fertilité \& Sénologie~2020.

12. Sanità, I.S.d., \emph{Rational use of individual protection devices
in the assistance of Covid-19 patients.}

13. Ferrazzi, E.M., et al., \emph{COVID-19 Obstetrics Task Force,
Lombardy, Italy: executive management summary and short report of
outcome.} International Journal of Gynecology \& Obstetrics.\textbf{n/a}
(n/a).

14. Guia d'actuació enfront de casos d'infecció pel nou coronavirus
SARS-CoV-2 en dones embarassades i nadons. Catalan Health Service.
Barcelona, S.A., 2020. {[}available in internet{]}
https://canalsalut.gencat.cat/web/.content/\_A-Z/C/coronavirus-2019-ncov/material-divulgatiu/guia-actuacio-embarassades.pdf.

15. Informació per a dones embarassades i les seves famílies. Ministry
of Health of the Government of Catalonia, S.a.i.i.h.c.g.c.w.c.

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