Management of COVID-19 in Second Trimester Pregnancy
Pregnant women with COVID-19 in the second trimester should continue routine antenatal care with appropriate infection control precautions, receive thromboprophylaxis if hospitalized, and undergo fetal growth surveillance 14 days after symptom resolution. 1
Initial Assessment and Triage
Outpatient Management (Mild Disease)
- Most pregnant women with symptomatic COVID-19 can be safely managed in the outpatient setting with intensive monitoring 2
- Implement protocol-driven telehealth follow-up to assess symptoms and arrange in-person visits when appropriate 2
- Warning signs requiring urgent evaluation:
- Fever
- Cough
- Shortness of breath
- Chest pain
- Nausea and vomiting (these symptoms are associated with higher likelihood of requiring admission) 2
Hospitalization Criteria
- Worsening respiratory symptoms
- Oxygen saturation <95% on room air
- Significant dehydration
- Inability to tolerate oral intake
- Signs of severe disease (respiratory rate >30, heart rate >120) 1
Laboratory Monitoring
For hospitalized patients, monitor coagulation parameters using pregnancy-specific reference ranges:
- D-dimer (normal in pregnancy: 0.16–1.7 μg/mL)
- PT ratio and APTT ratio (use ratio ≥1.5 as cut-off for coagulopathy)
- Fibrinogen (normal in pregnancy: higher than non-pregnant, 3.7-6.2 g/L in third trimester)
- Platelet count (admit if <100×10⁹/L) 3, 1
Thromboprophylaxis
- 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)
- For severe disease or elevated D-dimer levels, continue LMWH throughout pregnancy and postpartum
- 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
Respiratory Support
- Position in left lateral decubitus position when possible to maximize maternal cardiac output
- Consider differential diagnoses such as pulmonary embolism and sepsis, which may mimic or coexist with COVID-19 1
- Do not delay necessary radiological investigations due to pregnancy concerns 1
Fetal Monitoring and Delivery Planning
- COVID-19 alone is not an indication for cesarean delivery 1
- Decisions regarding timing, place, and mode of delivery should involve a multidisciplinary team including obstetricians, physicians, anesthetists, and intensivists 1
- Arrange fetal growth surveillance 14 days after symptom resolution 1
- Steroids for fetal lung maturation can be administered when indicated, as they have not been shown to cause more harm in COVID-19 1
Special Considerations
Coagulopathy Management
- Be aware that pregnant women with COVID-19 may present with a hyperfibrinolytic DIC phenotype (low fibrinogen and bleeding tendency), which differs from the thrombotic DIC seen in non-pregnant COVID-19 patients 3
- Monitor fibrinogen levels carefully, as hypofibrinogenemia is associated with postpartum hemorrhage 3
Risk Factors for Severe Disease
- Obesity (elevated BMI)
- Poorly controlled Type 2 diabetes mellitus
- These comorbidities increase risk of thrombotic complications including pulmonary embolism, ovarian vein thrombosis, and stroke 3
Follow-up Care
- Continue routine antenatal care with appropriate infection control precautions
- More stringent social distancing is recommended after 28 weeks of pregnancy 1
- Mental health assessment should be performed during every consultation 1
- Current evidence suggests no increased risk of miscarriage or teratogenicity (birth defects) 1
- Vertical transmission (mother-to-baby) is considered "probable" but rare 1
By following this structured approach to managing COVID-19 in second trimester pregnancy, healthcare providers can optimize maternal and fetal outcomes while minimizing risks associated with the infection.