Treatment of COVID-19 in Pregnancy
The management of COVID-19 in pregnant women should follow similar principles as in non-pregnant patients, with appropriate modifications for pregnancy and careful attention to thromboprophylaxis due to the increased risk of coagulopathy. 1, 2
General Management Principles
Outpatient Management (Mild Disease)
- Continue routine antenatal care unless symptomatic with COVID-19
- Implement more stringent social distancing after 28 weeks gestation
- For confirmed cases, arrange fetal growth surveillance 14 days after symptom resolution 1
- Monitor symptoms via telehealth when possible 3
- Consider home monitoring with:
Hospitalization Criteria
- Worsening respiratory symptoms (shortness of breath, chest pain)
- Fever unresponsive to antipyretics
- Inability to tolerate oral hydration
- Obstetric concerns requiring in-person evaluation 3
Specific Treatments
Respiratory Support
- Oxygen therapy to maintain saturation ≥95%
- Position pregnant women in lateral decubitus position when possible
- Continuous electronic fetal monitoring during labor for all suspected or confirmed cases 1
- Pregnancy is not a contraindication for advanced respiratory support including:
- Non-invasive ventilation
- Prone positioning (can be done with pregnancy modifications)
- Mechanical ventilation
- ECMO if necessary 4
Pharmacological Management
Corticosteroids
- Use non-fluorinated glucocorticoids for COVID-19 treatment in pregnancy 4
- Steroids for fetal lung maturation can be administered when indicated, as they have not been shown to cause more harm in COVID-19 1
Antiviral Therapy
- Remdesivir can be considered for pregnant patients with COVID-19 requiring hospitalization
- Dosage: 200 mg IV loading dose on day 1, followed by 100 mg IV daily 5
- Treatment duration:
- 5 days for hospitalized patients not requiring mechanical ventilation
- 10 days for patients requiring mechanical ventilation or ECMO
- 3 days for non-hospitalized high-risk patients 5
- Monitor liver function tests before and during treatment 5
Thromboprophylaxis
- Consider weight-adjusted low molecular weight heparin (LMWH) for all hospitalized pregnant women with COVID-19 1
- Continue LMWH unless delivery is imminent (within 24 hours) 1
- For patients with severe disease or high D-dimer levels in third trimester, continue LMWH throughout pregnancy and postpartum 1
- Duration of postpartum thromboprophylaxis: 2-6 weeks depending on severity of COVID-19 and other risk factors 1
- Mechanical prophylaxis (intermittent pneumatic compression) if anticoagulation is contraindicated 1
Labor and Delivery Considerations
- COVID-19 alone is not an indication for cesarean delivery
- Mode of delivery should be determined by standard obstetric indications 2
- Avoid birthing pools for women with suspected or confirmed COVID-19 1
- Healthcare providers should wear appropriate PPE during delivery 1
- An asymptomatic support person may be present during delivery 2
Postpartum Care
- Mother and baby should not be separated after birth 1, 2
- Breastfeeding is encouraged with appropriate hand hygiene and mask-wearing 1, 2
- Benefits of breastfeeding outweigh potential risks of viral transmission 1
Common Pitfalls to Avoid
- Don't delay necessary radiological investigations due to pregnancy concerns 1
- Don't withhold appropriate treatments due to unfounded concerns about fetal risk 4
- Don't overlook differential diagnoses such as pulmonary embolism and sepsis, which may mimic or coexist with COVID-19 1
- Don't forget mental health assessment during every consultation 1
- Don't neglect thromboprophylaxis - pregnancy and COVID-19 both increase thrombotic risk 1
Laboratory Monitoring
- Consider pregnancy-specific reference ranges when interpreting coagulation tests:
- D-dimer is normally elevated in pregnancy
- Fibrinogen is higher in pregnancy (normal range: 2.48-5.06 g/L in third trimester)
- PT and APTT are shortened in pregnancy 1
- Monitor for COVID-19 coagulopathy using:
- PT ratio and APTT ratio (≥1.5 indicates coagulopathy)
- Platelet count (≤100 × 10⁹/L defines thrombocytopenia)
- Fibrinogen levels (particularly important in obstetric setting) 1
By following these guidelines, clinicians can provide appropriate care for pregnant women with COVID-19 while minimizing risks to both mother and baby.