What is the recommended treatment approach for pregnant patients with COVID-19 (Coronavirus disease 2019)?

Management of COVID-19 in Pregnant Patients

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

General Treatment Approach

• Treatment should be guided by severity of illness, with a focus on supportive care as a bridge to recovery rather than delivery as a solution to recovery 2
• Basic principles of diagnosing and managing COVID-19 are the same as for non-pregnant patients 3
• Pregnant women should not be denied investigations or treatments due to unfounded concerns about fetal risk 3

Specific Management Considerations

Thromboprophylaxis (Critical)

• Weight-adjusted low molecular weight heparin (LMWH) is recommended for all hospitalized pregnant women with COVID-19 1
• Continue LMWH unless delivery is imminent (within 24 hours) 1
• For severe disease or elevated 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
• Use mechanical prophylaxis (intermittent pneumatic compression) if anticoagulation is contraindicated 1

Coagulation Monitoring

• Use PT ratio and APTT ratio with a ratio ≥1.5 as cut-off for coagulopathy, rather than relying on seconds 4
• Consider pregnancy-specific reference ranges when interpreting coagulation tests 1
• Monitor fibrinogen levels carefully, noting that normal pregnancy levels are higher (3.7-6.2 g/L in third trimester) 4

Pharmacological Treatment

• Corticosteroids should be modified to use non-fluorinated glucocorticoids during pregnancy 3
• IL-6 inhibitors, monoclonal antibodies, and specific antiviral therapies may be considered 3
• Steroids for fetal lung maturation can be administered when indicated without increased harm 1

Respiratory Support

• Oxygen therapy, non-invasive ventilation, prone positioning (even during pregnancy), intubation, and ECMO should not be withheld due to pregnancy 3
• Criteria for providing respiratory support are the same as in the general population 3
• Prone positioning can be safely performed in pregnant patients with appropriate support to avoid abdominal compression 2

Antenatal Care

• Routine antenatal care is considered essential and should continue with appropriate infection control precautions 4
• For confirmed COVID-19 cases, arrange fetal growth surveillance 14 days after symptom resolution 4, 1
• After 28 weeks, social distancing should be observed more stringently for all pregnant women 4, 1
• Consider differential diagnoses such as pulmonary embolism and sepsis, which may mimic or coexist with COVID-19 4

Delivery Considerations

• COVID-19 alone is not an indication for cesarean delivery 1
• Mode of delivery should be determined by standard obstetric indications 1
• Continuous electronic fetal monitoring is recommended during labor for all suspected or confirmed cases 4, 1
• Avoid birthing pools for women with suspected or confirmed COVID-19 1
• Decisions regarding timing, place, and mode of delivery should involve a multidisciplinary team including obstetricians, physicians, anesthetists, and intensivists 3
• Women are encouraged to have an asymptomatic partner, friend, or relative present during birth 4

Postpartum Care

• Mother and baby should not be separated after birth 1
• Breastfeeding is encouraged with appropriate hand hygiene and mask-wearing 1
• Benefits of breastfeeding outweigh potential risks of viral transmission 1
• Mental health assessment should be performed during every consultation 1

Special Considerations

• Current evidence suggests no increased risk of miscarriage, early pregnancy loss, or teratogenicity 1
• Vertical transmission (mother-to-baby) is considered "probable" but rare 1
• Some reports of preterm birth associated with COVID-19 infection have been documented 1
• Healthcare providers should wear appropriate PPE during delivery 1

Common Pitfalls to Avoid

• Do not delay necessary radiological investigations due to pregnancy concerns 1
• Do not withhold respiratory support interventions (including prone positioning and ECMO) due to pregnancy 3, 5
• Do not automatically resort to delivery as a treatment for maternal COVID-19; focus on supportive care 2
• Do not overlook the increased risk of thromboembolism in pregnant COVID-19 patients 4, 1
• Do not interpret coagulation tests using non-pregnant reference ranges 4