What are the treatment guidelines for COVID-19 (Coronavirus Disease 2019) in pregnant women?

Treatment Guidelines for COVID-19 in Pregnant Women

Pregnant women with COVID-19 should receive essential antenatal and postnatal care with appropriate precautions, while considering thromboprophylaxis and monitoring for complications including pulmonary embolism and sepsis. 1

General Management Principles

• Routine antenatal and postnatal care should continue for pregnant women, with modifications to reduce infection risk; women should attend appointments unless they have suspected or confirmed COVID-19 requiring self-isolation 1
• Consider differential diagnoses such as pulmonary embolism and sepsis when evaluating pregnant women with COVID-19 symptoms 1
• After 28 weeks of pregnancy, social distancing should be observed more stringently due to increased vulnerability 1
• Mental health assessment should be conducted during every consultation, with appropriate referrals made as needed 1

Thromboprophylaxis

• COVID-19 increases thromboembolism risk, which is already elevated in pregnancy (hypercoagulable state) 1
• Low molecular weight heparin should be considered for pregnant women with COVID-19, with dosing based on disease severity, timing of delivery, inpatient/outpatient status, and underlying comorbidities 1, 2
• Monitor coagulation parameters carefully, noting that pregnancy alters normal ranges:
  • PT and APTT ratios ≥1.5 should be used as cut-off for coagulopathy rather than absolute values in seconds 1
  • Fibrinogen levels require individualized assessment, with attention to hypofibrinogenemia which can be particularly dangerous in obstetric settings 1

Antenatal Care

• For confirmed COVID-19 cases, refer women for fetal growth surveillance via ultrasound 14 days after symptom resolution 1
• Carbon monoxide monitoring should be suspended during the pandemic 1
• Consider reducing the number of in-person visits at the discretion of the maternity unit; utilize telemedicine when appropriate 1, 3
• Essential ultrasound examinations should still be performed (nuchal translucency at 11-13+6 weeks, Oscar Test at 16 weeks, and fetal ultrasound at 20-24 weeks) 3

Intrapartum Care

• Continuous electronic fetal monitoring is recommended during labor for all cases of suspected or confirmed COVID-19 1
• Healthcare providers must wear appropriate personal protective equipment (PPE) when treating patients with suspected or confirmed COVID-19; this may cause delays in emergency situations, which should be communicated to patients 1
• Nitrous oxide (Entonox) can be used with a single patient microbiological filter 1
• No specific mode of birth is recommended based on COVID-19 status alone, but birthing pools should be avoided for women with suspected or confirmed COVID-19 1
• Steroids for fetal lung maturation can be administered when indicated and have not been shown to cause more harm in COVID-19 cases 1, 2
• Women may have an asymptomatic partner, friend, or relative present during birth 1

Critical Care Management

• Pregnant women with COVID-19 are at increased risk for ICU admission and mechanical ventilation compared to non-pregnant women of reproductive age 4, 5
• For mechanically ventilated pregnant patients, neuromuscular blockade should be used for the shortest duration possible 2, 5
• Dexamethasone is recommended for pregnant COVID-19 patients who are mechanically ventilated or require supplemental oxygen 2, 5
• In case of maternal cardiac arrest, high-quality CPR with lateral uterine displacement is essential, and perimortem cesarean delivery should be considered within 5 minutes if indicated 1

Postpartum Care

• Breastfeeding is encouraged as benefits outweigh the risks of infection transmission from mother to infant 1
• Mothers who test positive for COVID-19 and their healthy babies do not require separation 1
• Short courses of non-steroidal anti-inflammatory drugs can be used for postpartum analgesia, but opioids should be used cautiously due to risk of respiratory depression 2

Outpatient Management

• Most pregnant women with symptomatic COVID-19 can be managed in outpatient settings with intensive protocol-driven monitoring 6
• Telehealth follow-up is effective for monitoring symptoms and determining need for in-person evaluation 3, 6
• Symptoms that should prompt consideration for hospital admission include fever, cough, shortness of breath, chest pain, or nausea and vomiting 6

Medication Considerations

• Hydroxychloroquine, lopinavir/ritonavir, and remdesivir may be used during pregnancy and lactation within clinical trials, but data from non-pregnant populations have not shown clear benefit 2
• The role of monoclonal antibodies, immunomodulators, interferon, inhaled nitric oxide, and convalescent plasma in pregnancy requires further evaluation 2