What is the management approach for a pregnant woman who tests positive for Covid-19 (Coronavirus disease 2019)?

Management of COVID-19 Positive Pregnant Women

Pregnant women with COVID-19 should continue routine antenatal care with appropriate infection control precautions, receive thromboprophylaxis based on disease severity, undergo enhanced fetal monitoring, and can safely breastfeed and remain with their newborns postpartum. 1

Risk Stratification and Monitoring

Pregnant women with COVID-19 face increased risk of severe disease compared to non-pregnant women of reproductive age. After adjusting for age and comorbidities, pregnant women are 1.5 times more likely to require ICU admission and 1.7 times more likely to need mechanical ventilation, though mortality risk remains similar. 2 Approximately one-third of pregnant women with COVID-19 require hospitalization compared to only 5.8% of non-pregnant women. 2

Outpatient Management Criteria

Most pregnant women with symptomatic COVID-19 can be managed as outpatients with protocol-driven telehealth monitoring. 3 However, immediate evaluation for hospitalization is warranted if patients develop fever, cough, shortness of breath, chest pain, or nausea/vomiting, as these symptoms predict disease progression requiring admission. 3

Key monitoring parameters for outpatient management include:

• Systematic telehealth follow-up by clinician team to assess symptom progression 3
• Virtual prenatal care with in-person visits only when medically necessary 1
• Consider differential diagnoses including pulmonary embolism and sepsis, which can mimic COVID-19 worsening 1
• Mental health assessment at every consultation 1

Thromboprophylaxis

Low molecular weight heparin should be administered to pregnant women with COVID-19, with dosing determined by disease severity, hospitalization status, timing relative to delivery, and underlying comorbidities. 1 This addresses the compounded thrombotic risk from both pregnancy's hypercoagulable state and COVID-19-associated coagulopathy. 1

Coagulation Monitoring

Pregnancy alters normal coagulation parameters, requiring pregnancy-specific interpretation:

• Use PT ratio and APTT ratio ≥1.5 as the cut-off for coagulopathy rather than absolute values in seconds 4
• Monitor fibrinogen with individualized assessment, paying particular attention to hypofibrinogenemia which predicts severe postpartum hemorrhage 4
• Use platelet count threshold of ≤100 × 10⁹/L to define clinically significant thrombocytopenia 4
• D-dimer cut-off of 2.0 μg/mL predicts severe disease and mortality 4

Antenatal Care Modifications

Gestational Age-Specific Precautions

• After 28 weeks gestation, enforce more stringent social distancing measures due to increased vulnerability 4, 1
• Suspend carbon monoxide monitoring during the pandemic 4, 1
• For confirmed COVID-19 cases, refer for fetal growth surveillance ultrasound 14 days after symptom resolution 4, 1

Timing of Prenatal Visits

Encourage postponement of non-essential visits except:

• Nuchal translucency at 11-13+6 weeks 5
• Screening tests at 16 weeks 5
• Fetal ultrasound at 20-24 weeks 5

Intrapartum Management

Labor and Delivery Protocols

Continuous electronic fetal monitoring is mandatory during labor for all suspected or confirmed COVID-19 cases. 4, 1 This differs from standard intermittent monitoring protocols.

Personal protective equipment requirements:

• Healthcare providers must wear appropriate PPE when treating suspected or confirmed COVID-19 patients 4, 1
• Warn patients and families that PPE donning may cause delays in obstetric emergencies 4
• One asymptomatic support person (no symptoms in past 7 days) may be present during birth 4

Anesthesia and Pain Management

• Nitrous oxide (Entonox) can be safely used with a single-patient microbiological filter 4, 1
• Radiology investigations should proceed without delay when indicated, regardless of fetal concerns 4

Mode of Delivery

• COVID-19 status alone does not dictate mode of delivery; obstetric indications should guide this decision 4, 1
• Avoid birthing pools for women with suspected or confirmed COVID-19 4, 1
• Steroids for fetal lung maturation are not contraindicated and should be administered when indicated 4

Postpartum Fever Recognition

Pregnant women may not develop fever until after delivery, with low-grade postpartum fever (37.5-38.5°C) within 24 hours being a common initial presentation. 6 This atypical presentation requires high clinical suspicion and immediate CT imaging plus RT-PCR testing to prevent cross-infection. 6

Postpartum Care

Mother-Infant Interaction

Mothers who test positive for COVID-19 and their healthy newborns do not require separation. 4, 1 This represents a critical departure from early pandemic protocols.

Breastfeeding should be encouraged as the benefits outweigh the risks of viral transmission from mother to infant. 4, 1

Viral Clearance Timeline

The median duration from initial positive test to RT-PCR viral clearance is 26 days, with no significant variation by trimester of infection. 3 This prolonged viral shedding should inform isolation precautions and return-to-work planning.

Common Pitfalls to Avoid

• Do not rely on absence of antepartum fever to exclude COVID-19—many pregnant women develop fever only postpartum 6
• Do not use non-pregnancy coagulation reference ranges—this leads to misdiagnosis of coagulopathy 4
• Do not delay indicated radiology or interventions due to fetal concerns—maternal stabilization is paramount 4
• Do not separate mothers from healthy newborns based solely on maternal COVID-19 status—this causes unnecessary psychological harm without proven benefit 4, 1