What is the recommended treatment for a pregnant patient with COVID-19 (Coronavirus Disease 2019) who is hemodynamically stable?

From the Guidelines

For a COVID-19 positive pregnant patient who is hemodynamically stable, I recommend a supportive care approach with close monitoring, as outlined in the BMJ study 1, which emphasizes the importance of routine antenatal and postnatal care, consideration of differentials to COVID-19, and assessment of mental health.

Key Recommendations

• Treatment should include acetaminophen (650 mg every 6 hours as needed) for fever and pain management, adequate hydration, and rest, as these interventions help manage symptoms and prevent complications.
• Regular assessment of oxygen saturation (maintain >95%), vital signs, and laboratory parameters including complete blood count, liver function, and renal function is essential, as highlighted in the Journal of Thrombosis and Haemostasis study 1.
• Consideration of antenatal corticosteroids for fetal lung maturity if preterm delivery is anticipated, and maintenance of continuous fetal monitoring if gestational age is viable, are crucial for ensuring fetal wellbeing.
• The use of remdesivir, nirmatrelvir-ritonavir (Paxlovid), and dexamethasone may be considered for moderate to severe symptoms or if the patient has risk factors for progression to severe disease, as discussed in the American Journal of Obstetrics and Gynecology study 1.

Rationale

The recommended treatment approach prioritizes supportive care and close monitoring, as the current evidence base for COVID-19 treatment in pregnancy is limited, and most clinical trials exclude pregnant subjects 1. However, the available studies emphasize the importance of routine antenatal and postnatal care, consideration of differentials to COVID-19, and assessment of mental health 1. The use of acetaminophen, hydration, and rest, as well as regular assessment of oxygen saturation and laboratory parameters, are essential for managing symptoms and preventing complications. The consideration of antenatal corticosteroids and continuous fetal monitoring also ensures fetal wellbeing.

Considerations

• The risk of venous thromboembolism is increased in people with COVID-19, and pregnancy is a known hypercoagulable state, as highlighted in the BMJ study 1.
• Health professionals should inquire about mental health during every consultation and connect women to relevant resources, if required, as emphasized in the BMJ study 1.
• The use of remdesivir, nirmatrelvir-ritonavir (Paxlovid), and dexamethasone should be considered on a case-by-case basis, taking into account the patient's risk factors and symptoms, as discussed in the American Journal of Obstetrics and Gynecology study 1.

From the FDA Drug Label

PAXLOVID is indicated for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults who are at high risk for progression to severe COVID-19, including hospitalization or death.

Initiate PAXLOVID treatment as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset.

The recommended dosage is 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet), with all 3 tablets taken together twice daily for 5 days.

The recommended treatment for a pregnant patient with COVID-19 who is hemodynamically stable is nirmatrelvir (PAXLOVID), with a dosage of 300 mg nirmatrelvir with 100 mg ritonavir, twice daily for 5 days. However, it is crucial to note that the label does not explicitly address pregnancy, and therefore, the decision to use PAXLOVID in a pregnant patient should be made with caution and under the guidance of a healthcare professional, considering the potential benefits and risks 2.

Alternatively, remdesivir (VEKLURY) is also an option for the treatment of COVID-19. The recommended dosage for adults is a single loading dose of 200 mg on Day 1, followed by once-daily maintenance doses of 100 mg from Day 2 3.

From the Research

Treatment for Pregnant Patients with COVID-19

The recommended treatment for a pregnant patient with COVID-19 who is hemodynamically stable includes:

• Antenatal corticosteroids for fetal lung maturation between 24 and 34 weeks' gestation, with decisions made on a case-by-case basis for those with critical illness or outside this gestational age range 4
• Magnesium sulfate for seizure prophylaxis and fetal neuroprotection, used cautiously in those with hypoxia and renal compromise 4
• Low-dose aspirin to prevent placenta-mediated pregnancy complications when indicated, with no contraindications 4
• Thromboprophylaxis, with an algorithm considering disease severity, timing of delivery, inpatient vs outpatient status, underlying comorbidities, and contraindications to anticoagulation 4
• Remdesivir, which has shown improved clinical condition in pregnant patients with COVID-19, especially those with better clinical status at baseline and earlier treatment, although its use should be followed with careful monitoring of adverse reactions and transaminase enzyme levels 5
• Dexamethasone, which is the only proven and recommended experimental treatment for pregnant patients with COVID-19 who are mechanically ventilated or require supplemental oxygen 4, 6

Considerations for Labor and Delivery

Considerations for labor and delivery in pregnant patients with COVID-19 include:

• Use of nitrous oxide for labor analgesia with appropriate personal protective equipment 4
• Intravenous remifentanil patient-controlled analgesia, used with caution in patients with respiratory depression 4
• Liberal use of neuraxial labor analgesia to reduce the need for emergency general anesthesia, which results in aerosolization 4
• Short courses of non-steroidal anti-inflammatory drugs for postpartum analgesia, with opioids used with caution due to the risk of respiratory depression 4

Ongoing Care and Monitoring

Ongoing care and monitoring for pregnant patients with COVID-19 include:

• Continuous evidence surveillance to ensure clinicians have reliable, evidence-based guidelines for clinical decision-making 6
• Monitoring for adverse reactions and transaminase enzyme levels in patients treated with remdesivir 5
• Consideration of the potential substantial adverse maternal and neonatal outcomes associated with COVID-19 during pregnancy 7