What is the recommended treatment for COVID-19 in pregnant women?

Treatment of COVID-19 in Pregnant Women

Pregnant women with COVID-19 should receive thromboprophylaxis with low molecular weight heparin, appropriate respiratory support, and continued essential antenatal care while monitoring for complications including pulmonary embolism and sepsis. 1

Risk Assessment and General Management

• Pregnant women are at increased risk for severe COVID-19 disease compared to non-pregnant women of reproductive age 2
• Routine antenatal and postnatal care should continue with appropriate infection control precautions, with modifications to reduce infection risk 1
• After 28 weeks of pregnancy, more stringent social distancing should be observed due to increased vulnerability 1
• Mental health assessment should be conducted during every consultation with appropriate referrals as needed 1

Thromboprophylaxis - Critical Component

• COVID-19 significantly increases thromboembolism risk, which is already elevated in pregnancy (hypercoagulable state - 4-6 fold increased risk compared to non-pregnant women) 1, 2
• Low molecular weight heparin (LMWH) should be administered for pregnant women with COVID-19 requiring hospitalization, in the absence of active bleeding 2
• Thromboprophylaxis should also be considered for pregnant women with COVID-19 managed at home if they have risk factors such as immobility, high fever, dehydration, or additional maternal risk factors for VTE 2
• Monitor coagulation parameters carefully, noting that pregnancy alters normal ranges:
  • Use PT and APTT ratios ≥1.5 as cut-off for coagulopathy rather than absolute values 3, 1
  • Individualized assessment of fibrinogen levels is required, with particular attention to hypofibrinogenemia which can be dangerous in obstetric settings 3, 1

Antenatal Care Modifications

• For confirmed COVID-19 cases, refer women for fetal growth surveillance via ultrasound 14 days after symptom resolution 1
• Consider differential diagnoses such as pulmonary embolism and sepsis when evaluating pregnant women with COVID-19 symptoms 1
• For severe cases, continuous electronic fetal monitoring is recommended during labor 1

Intrapartum Management

• No specific mode of birth is recommended based on COVID-19 status alone 1
• Healthcare providers must wear appropriate personal protective equipment (PPE) when treating patients with suspected or confirmed COVID-19 1
• Nitrous oxide (Entonox) can be used with a single patient microbiological filter 1
• Birthing pools should be avoided for women with suspected or confirmed COVID-19 1

Critical Care Management

• For severe respiratory compromise:
  • Continuous electronic fetal monitoring is recommended 1
  • In case of maternal cardiac arrest, high-quality CPR with lateral uterine displacement is essential 1
  • 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
• Continue thromboprophylaxis based on disease severity, D-dimer levels, and individual risk factors 2

Special Considerations

• The International Society on Thrombosis and Haemostasis (ISTH) has established an international registry to gather more data on coagulopathies in COVID-19-affected pregnancies 2
• COVID-19 infection during pregnancy can exacerbate the hypercoagulable state, potentially leading to increased risk of preeclampsia or eclampsia (adjusted odds ratio 1.57) 2

Common Pitfalls to Avoid

• Failing to recognize that normal pregnancy-related changes in coagulation parameters may mask COVID-19 coagulopathy 3
• Overlooking the need for thromboprophylaxis in outpatient settings for pregnant women with COVID-19 who have additional risk factors 2
• Delaying fetal growth surveillance after COVID-19 recovery 1
• Separating mothers from babies unnecessarily, which can interfere with bonding and breastfeeding 1