ANTENATAL MANAGEMENT OF WOMEN WITH COVID-19 INFECTION
Based on currently available data, the clinical characteristics of pregnant women with COVID-19 infection are similar to those of non-pregnant adults. This includes the risk of progression to severe respiratory disease and need for mechanical ventilation with reported rates of between 1.6 to 5.3 percent, similar to that of the non-pregnant population.10, 11
COVID-19 infection does not appear to increase the risk of adverse pregnancy outcomes. The only case-control study available that compares pregnant women with COVID-19 infection to those without did not demonstrate any differences in the rates of preeclampsia, gestational diabetes and premature rupture of membranes.12 These findings were in agreement with a systematic review of 114 pregnant women with COVID-19 infection, which concluded that the maternal and perinatal outcomes appeared similar to the general obstetric population.10 In contrast, another systematic review evaluating pregnancy outcomes in 79 women with COVID-19 infection suggested higher rates of preterm birth before 37 and 34 weeks (41.1 and 15 percent, respectively), premature rupture of membranes (18.8 percent) and preeclampsia (13.6 percent).13 Similarly, 17 percent of those with COVID-19 infection in pregnancy included in the UKOSS study delivered before 37 weeks compared to only 8 percent in those without.6 Although the association between COVID-19 infection in pregnancy and adverse outcomes remains to be determined, there is a well-established relationship between other viral pneumonias and pre-term birth and/or premature rupture of membranes.3, 14 Therefore, It is possible that as the pandemic evolves and the quality of evidence improves, a similar association with COVID-19 may emerge. Furthermore, it remains unknown as to the impact of COVID-19 infection when occurring early in pregnancy due to the lack of first trimester data.
Higher rates of fetal growth restriction (FGR) have not so far been reported with COVID-19. However, in one case series and one systematic review that evaluated outcomes of pregnancies complicated by SARS, a significantly higher incidence of FGR was demonstrated with rates of 16.6 and 18.5 percent, respectively.4, 13 Based on this data and until more evidence is available for COVID-19, ISUOG recommend 2 to 4 weekly fetal ultrasound assessment9and FIGO8 recommend monthly. The RCOG does not make any recommendation as to the frequency of ultrasound assessment in women with COVID-19 infection in pregnancy but states that, during the pandemic, non-routine growth scans that are not guidance-based should be kept to a minimum.7
Outside of pregnancy, women of black racial origin have a 4-fold increase in the risk of death from COVID-19 when compared to their white counterparts.15 A number of theories have been proposed to account for this trend. These include genetic, health and socioeconomic disparities leading to increased exposure and susceptibility to COVID-19 infection in those of black racial origin such as a higher prevalence of hypertension and diabetes16 or ethnic variations in the expression of angiotensin converting enzyme 2, the host receptor of SARS-CoV-2.17 Similarly, in pregnancy, COVID-19 appears to have a more severe impact on those of black and ethnic minority with an almost 4-fold increase (OR 3.67, 95%CI 2.55-5.28) in the risk of needing hospital admission even after adjustment for body mass index, co-morbidities, age and geographical location.6 Prior to the pandemic, pregnant women of black racial origin were already disproportionately represented amongst those who died with a 5-fold increase in the risk of death.18 In recognition of this, the RCOG guidelines recommend that pregnant women of black and ethnic minority background and clinicians should have a much lower threshold to escalate care should there be concerns regarding their health.7
To minimise the risk of transmission to other pregnant women and healthcare providers, any scheduled antenatal appointments in women with COVID-19 infection should be delayed until after the period of self-isolation. If obstetric or midwifery appointments are deemed necessary and cannot be carried out virtually, then all guidelines recommend that those appointments are kept to the end of the day and that staff are notified of the need to wear Personal Protection Equipment (PPE) with subsequent deep cleaning of the room and any equipment utilised.7-9 There is no evidence for the above recommendations regarding antenatal appointments but are largely based on expert opinion.