What is the management plan for a pregnant woman at 37 weeks of gestation with Coronavirus Disease 2019 (COVID-19)?

From the Guidelines

Management of a pregnant woman at 37 weeks with COVID-19 requires careful monitoring of both maternal and fetal health while addressing the viral infection. The patient should be assessed for symptom severity to determine appropriate care setting—mild cases can be managed at home with isolation, while moderate to severe cases require hospitalization. For mild symptoms, supportive care includes acetaminophen (650 mg every 6 hours as needed) for fever and pain, adequate hydration, and rest. Oxygen saturation should be monitored regularly with a home pulse oximeter, maintaining levels above 95%. For moderate to severe disease, hospitalization is necessary with supplemental oxygen therapy if saturation falls below 94%. Remdesivir (200 mg IV on day 1, followed by 100 mg IV daily for 4 days) may be considered, particularly for those with risk factors for progression, as suggested by studies such as 1. Dexamethasone (6 mg IV or oral daily for up to 10 days) is recommended for patients requiring oxygen.

Regarding obstetric management, twice-weekly fetal monitoring with non-stress tests should be performed, and delivery timing should be individualized—COVID-19 alone is not an indication for delivery unless maternal condition deteriorates. If delivery is necessary, vaginal delivery is preferred when possible, with appropriate PPE for healthcare workers. Thromboprophylaxis with enoxaparin (40 mg subcutaneously daily) should be considered during hospitalization due to increased thrombotic risk with both pregnancy and COVID-19, as highlighted in studies like 1 and 1. After delivery, breastfeeding is encouraged with proper hand hygiene and mask-wearing, as the benefits outweigh potential risks of transmission.

Key considerations include:

• Monitoring for coagulopathy, as COVID-19 can increase the risk of thrombotic events, especially in pregnant women, as discussed in 1.
• The use of neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic, which can be beneficial for pain management during delivery, as reviewed in 1.
• Vaccination recommendations for pregnant and lactating women, which vary by country but generally prioritize mRNA vaccines, as outlined in 1.

Overall, the management plan should prioritize both maternal and fetal health, taking into account the specific risks and considerations associated with COVID-19 in pregnancy.

From the Research

Management Plan for a Pregnant Lady in 37 Weeks with COVID-19

• The management plan for a pregnant lady in 37 weeks with COVID-19 should be based on a multidisciplinary approach, involving obstetricians, physicians, anesthetists, and intensivists experienced in the care of COVID-19 in pregnancy 2.
• The basic principles of diagnosing and managing COVID-19 are the same as for non-pregnant patients, with consideration for the pregnant state 2.
• Treatment with corticosteroids should be modified to use non-fluorinated glucocorticoids, and IL-6 inhibitors and monoclonal antibodies, together with specific antiviral therapies, may also be considered 2.
• Prophylaxis against venous thromboembolism is important, and women may require respiratory support with oxygen, non-invasive ventilation, ventilation in a prone position, intubation and ventilation, and extracorporeal membrane oxygenation (ECMO) 2.

Antiviral Therapy

• Remdesivir has been shown to significantly reduce the time to recovery and mortality in COVID-19 patients, and may be considered as part of the treatment plan 3, 4.
• Dexamethasone has been shown to reduce mortality by one-third in hospitalized patients with severe or critical COVID-19, and may be considered as part of the treatment plan 3, 4.
• Monoclonal antibody combinations, such as bamlanivimab/etesevimab and casirivimab/imdevimab, have received emergency use authorizations for use in non-hospitalized patients with mild-to-moderate COVID-19 at high risk of disease progression 4.

Delivery Planning

• Decisions regarding timing, place, and mode of delivery should be taken with a multidisciplinary team, including obstetricians, physicians, anesthetists, and intensivists experienced in the care of COVID-19 in pregnancy 2.
• Ideally, these decisions should take place in consultation with centers that have experience and expertise in all these specialties 2.
• The management plan should be individualized to the patient's specific needs and circumstances, taking into account the latest guidelines and evidence-based practices 5, 6.