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.