Management of COVID-19 in Pregnant Women
For pregnant women with COVID-19, management should include thromboprophylaxis with weight-adjusted low molecular weight heparin for all hospitalized cases, regular fetal monitoring, continuation of routine antenatal care with appropriate infection control measures, and vaccination according to current guidelines, as recommended by multiple obstetric societies. 1
Risk Assessment and Initial Management
- COVID-19 in pregnancy presents unique challenges with current data showing 7-10% ICU admissions and approximately 1% maternal mortality 2
- Pregnant women are more vulnerable to COVID-19 complications due to physiological and immunological changes of pregnancy 3
- Initial assessment should include:
- Evaluation of respiratory status (oxygen saturation, respiratory rate)
- Laboratory monitoring including coagulation parameters (D-dimer, PT, APTT, fibrinogen, platelet count) using pregnancy-specific reference ranges 1
- Assessment for signs of disease progression
Thromboprophylaxis
- All hospitalized pregnant women with COVID-19 should receive weight-adjusted low molecular weight heparin (LMWH) 1
- LMWH should be continued unless delivery is imminent (within 24 hours)
- For severe disease or elevated D-dimer levels in the third trimester, continue LMWH throughout pregnancy and postpartum
- Duration of postpartum thromboprophylaxis should be 2-6 weeks, depending on disease severity and other risk factors 1
- Use mechanical prophylaxis (intermittent pneumatic compression) if anticoagulation is contraindicated
Antiviral Treatment
- Remdesivir can be considered for pregnant patients with COVID-19, as pharmacokinetic studies show similar exposures during pregnancy compared to non-pregnant individuals 4
- The FDA-approved antiviral has shown activity against SARS-CoV-2 and its pharmacokinetics are not affected by pregnancy 4
Fetal Monitoring and Delivery Planning
- Regular fetal growth surveillance should be arranged after maternal symptom resolution 1
- Continuous electronic fetal monitoring is recommended during labor for all suspected or confirmed cases 1
- COVID-19 alone is not an indication for cesarean delivery; mode of delivery should be determined by standard obstetric indications 1
- Decisions regarding timing, place, and mode of delivery should involve a multidisciplinary team including obstetricians, physicians, anesthetists, and intensivists 1
Postpartum Care
- Mother and baby should not be separated after birth 1
- Breastfeeding is encouraged with appropriate hand hygiene and mask-wearing 1
- A multimodal approach to postpartum pain management should be used, starting with non-opioid analgesics 1
- Mental health assessment should be performed during every consultation 1
Vaccination and Infection Prevention
- Vaccination is strongly recommended for pregnant women 2, 1
- Different countries have varying policies, but most major obstetric organizations including ACOG recommend vaccination in pregnant and lactating women 2
- The mRNA vaccines are specifically approved for use in pregnancy 2
- Pregnant women and household members should follow infection prevention measures:
- Wearing masks
- Social distancing
- Frequent handwashing
- Avoiding contact with individuals exposed to COVID-19 1
Outpatient Management
- Asymptomatic COVID-19-positive pregnant women do not require immediate hospitalization 1
- Routine antenatal care should continue with appropriate infection control precautions 1
- Consider telemedicine services and remote fetal heart rate monitoring when appropriate 5
- Asymptomatic patients should self-monitor for symptoms, have regular virtual check-ins with their healthcare provider, and promptly report any new symptoms 1
Important Considerations
- Current evidence suggests no increased risk of miscarriage or early pregnancy loss, and no evidence of teratogenicity (birth defects) has been found 1
- Pregnant women with COVID-19 should be evaluated for signs of fetal growth restriction 1
- Healthcare providers should wear appropriate PPE during delivery 1
By following these evidence-based recommendations, healthcare providers can optimize outcomes for both mother and baby in the context of COVID-19 infection during pregnancy.