What is the management plan for Covid-19 (Coronavirus disease 2019) in pregnancy?

Management of COVID-19 in Pregnancy

Pregnant women with COVID-19 should receive thromboprophylaxis with weight-adjusted low molecular weight heparin (LMWH) during hospitalization, with continued monitoring for coagulation abnormalities and consideration of extended prophylaxis for 2-6 weeks postpartum depending on disease severity and risk factors. 1

Clinical Presentation and Risk Assessment

• Pregnant women with COVID-19 typically present with:

  • Fever (87.6%)
  • Cough (52.3%)
  • Dyspnea (27.6%)
  • Fatigue (22.4%)
  • Sore throat (13.5%)
  • Malaise (9.4%)
  • Diarrhea (3.4%) 2

• Risk factors for severe COVID-19 in pregnancy:

  • Third trimester of pregnancy (highest risk period)
  • Obesity
  • Diabetes
  • Maternal age >40 years 3
  • Pre-existing comorbidities 4

Diagnostic Evaluation

• Laboratory testing:

  • Standard COVID-19 testing (PCR or rapid antigen)
  • Complete blood count
  • Comprehensive metabolic panel
  • Coagulation parameters (D-dimer, PT ratio, APTT ratio, fibrinogen, platelet count) using pregnancy-specific reference ranges 1

• Imaging:

  • Chest radiography with appropriate shielding if clinically indicated
  • CT scan findings often show multiple mottling and ground-glass opacities 5

Management Approach

Outpatient Management (Mild Disease)

• Asymptomatic or mildly symptomatic pregnant women do not require hospitalization 1
• Implement:
  • Regular virtual check-ins with healthcare providers
  • Self-monitoring for symptom progression
  • Prompt reporting of new or worsening symptoms
  • Continuation of routine antenatal care with appropriate infection control precautions 1

Inpatient Management (Moderate to Severe Disease)

1. Respiratory Support:

   • Oxygen therapy as needed to maintain maternal SpO2 ≥95%
   • Position in left lateral decubitus position when possible to optimize uteroplacental perfusion
   • Early consideration of mechanical ventilation if respiratory status deteriorates 4

2. Thromboprophylaxis:

   • Weight-adjusted LMWH for all hospitalized pregnant women with COVID-19
   • Continue LMWH throughout pregnancy and postpartum (2-6 weeks) for severe disease or elevated D-dimer levels
   • Use mechanical prophylaxis (intermittent pneumatic compression) if anticoagulation is contraindicated 1

3. Fetal Monitoring:

   • Regular fetal growth surveillance after maternal symptom resolution
   • Continuous electronic fetal monitoring during labor for all suspected or confirmed cases 1

4. Delivery Planning:

   • COVID-19 alone is not an indication for cesarean delivery
   • Mode of delivery should be determined by standard obstetric indications
   • Multidisciplinary team approach involving obstetricians, physicians, anesthetists, and intensivists 1
   • Neuroaxial analgesia during labor is encouraged 1

5. Postpartum Care:

   • Mother and baby should not be separated after birth
   • Breastfeeding is encouraged with appropriate hand hygiene and mask-wearing
   • Multimodal approach to postpartum pain management starting with non-opioid analgesics 1

Special Considerations

Coagulopathy Management

• COVID-19 in pregnancy presents unique challenges due to the hypercoagulable state of pregnancy combined with COVID-19-associated coagulopathy 6
• Monitor for signs of thrombotic complications and disseminated intravascular coagulopathy
• Adjust thromboprophylaxis based on disease severity and laboratory parameters 6

Maternal and Fetal Outcomes

• Pregnant women with COVID-19 have increased risk of:

  • Hospitalization and ICU admission compared to non-pregnant individuals 4
  • Preterm birth (12.9% vs 10.2% in general population) 7
  • Cesarean delivery 2

• No evidence of increased risk of:

  • Miscarriage or early pregnancy loss
  • Teratogenicity (birth defects) 1

• Vertical transmission is possible but rare (2.6%), primarily occurring when maternal infection is identified within 1 week of delivery 7

Prevention Strategies

• Vaccination according to current guidelines
• Pregnant women and household members should follow infection prevention measures:
  • Wearing masks
  • Social distancing
  • Frequent handwashing
  • Avoiding contact with individuals exposed to COVID-19 7
• Regular COVID-19 screening during prenatal visits 2

Common Pitfalls to Avoid

• Delaying thromboprophylaxis in hospitalized pregnant women with COVID-19
• Separating mothers and infants unnecessarily after birth
• Using potent broad-spectrum antibiotics and corticosteroids without clear indications 2
• Performing cesarean delivery solely due to COVID-19 status 1
• Neglecting mental health assessment during consultations 1