Update By The American College of Obstetricians and Gynecologists Regarding COVID-19 and Pregnancy

As the pandemic continues health care providers and experts and gaining a greater understanding of COVID-19. 

This means that as new information comes out we will see changes in guidelines and recommendations. The CDC reports that these alterations are done based on existing science and after a thorough technical review of the guidance.

The American College of Obstetricians and Gynecologists issued a summary of key updates in the beginning of November regarding COVID-19 and pregnancy. They reported that available data suggests that symptomatic pregnant women with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers. Given the growing evidence, the CDC now includes pregnant women in its “increased risk” category for COVID-19 illness. Specifically, these data indicate a small but significant risk of ICU admissions, mechanical ventilation, and death reported in pregnant women with symptomatic COVID-19 infection (as compared with symptomatic non-pregnant women). Pregnant patients with comorbidities such as obesity and gestational diabetes may be at a higher risk of severe illness consistent with the general population with similar comorbidities. 

While the data from the CDC points out an increase in risk of severe outcomes in pregnant women with symptomatic SARS-CoV-2 infection, the absolute risk is still substantially lower than that of pandemic H1N1 influenza infection during pregnancy. During the H1N1 influenza pandemic, pregnant women made up 5% of deaths, despite only making up 1% of the population and pregnancy risk of ICU admission was reported as high as a 7-fold increase.

Some other important highlights are:

1. Patient Education

Clinicians should counsel pregnant women and those contemplating pregnancy about the potential risk of COVID-19. Measures to prevent infection with SARS-CoV-2 should be emphasized for pregnant women and their families. Pregnant individuals are encouraged to take all available precautions to avoid exposure to COVID-19 and optimize health including: 

• maintaining prenatal care appointments
• wearing a mask and other recommended PPE, if applicable, at work and in public
• washing hands frequently
• maintaining physical distancing
• limiting contact with other individuals as much as practicable
• maintaining an adequate supply of preparedness resources including medications

2. Contact Between Mother And Child

The recent guidance states that early and close contact between the mother and neonate has many well-established benefits including increased success with breastfeeding, facilitation of mother-infant bonding, and promotion of family-centered care. Given the available evidence on this topic, mother-infant dyads where the mother has suspected or confirmed SARS-CoV-2 infection should ideally room-in according to usual facility policy. Although data is still emerging and long-term effects are not yet fully understood, data suggests that there is no difference in risk of SARS-CoV-2 infection to the neonate whether a neonate is cared for in a separate room or remains in the mother’s room. Importantly, any determination of whether to keep individuals with known or suspected SARS-CoV-2 infection and their infants together or separate after birth should include a process of shared decision-making with the patient, their family, and the clinical team. This issue should be raised during prenatal care and continue through the intrapartum period. Healthcare providers should respect maternal autonomy in the medical decision-making process. Decision-making around rooming-in or separation should be free of any coercion, and facilities should implement policies that protect an individual’s informed decision. 

For mothers with suspected or confirmed COVID-19, rooming-in should be combined with safety measures to minimize the risk of transmission, including:

• Mother using a mask or cloth face covering and practicing hand hygiene prior to and during all contact with the neonate. Masks or cloth face coverings should not be placed on neonates or children younger than 2 years of age.
• Engineering controls such as using physical barriers (eg, placing the neonate in a temperature-controlled isolette) and keeping the neonate 6 feet or more away from the mother as often as possible.
• If it is possible to have a non-health care professional caregiver provide care for the neonate while in the hospital, it should be an individual who is not at increased risk for severe illness and uses appropriate infection prevention precautions (e.g., wearing a mask, practicing hand hygiene).

They go on to say that while enabling rooming-in is a key practice to encourage and support breastfeeding, there may be circumstances (related to COVID-19 or otherwise) where temporary separation is appropriate for the well-being of the mother and neonate. Decisions about temporary separation should be made in accordance with the mother’s wishes. Considerations for counseling patients considering temporary separation include:

• Mothers with suspected or confirmed SARS-CoV-2 infection do not pose a potential risk of virus transmission to their neonates if they have met the criteria for discontinuing isolation and precautions:
• At least 10 days have passed since their symptoms first appeared (up to 20 days if they have more severe to critical illness or are severely immunocompromised), and
• At least 24 hours have passed since their last fever without the use of antipyretics, and
• Their other symptoms have improved.
• Mothers who have not met these criteria may choose to temporarily separate from their neonates in an effort to reduce the risk of virus transmission. However, if after discharge they will not be able to maintain separation from their neonate until they meet the criteria, it is unclear whether temporary separation while in the hospital would ultimately prevent SARS-CoV-2 transmission to the neonate, given the potential for exposure from the mother after discharge.
• Separation may be necessary for mothers who are too ill to care for their infants or who need higher levels of care.
• Separation may be necessary for neonates at higher risk for severe illness (e.g., preterm infants, infants with underlying medical conditions, infants needing higher levels of care).
• Consideration for separation as an approach to reduce the risk of transmission from a mother with suspected or confirmed SARS-CoV-2 to her neonate is not necessary if the neonate tests positive for SARS-CoV-2.

3. Breast Feeding

It is not known whether COVID-19 can be transmitted through breastmilk, or if any potential viral components, if transmitted, are infectious. Although a recent case report detected SARS-CoV-2 RNA in the breastmilk, the majority of the data has not demonstrated the presence of SARS-CoV-2 virus in breastmilk. Therefore, suspected or confirmed maternal COVID-19 is not considered a contraindication to infant feeding with breastmilk at this time.

However, individuals with suspected or confirmed COVID-19 can transmit the virus through respiratory droplets while in close contact with the infant (including while breastfeeding). Therefore, obstetrician-gynecologists and other maternal care practitioners should counsel women with suspected or confirmed COVID-19 who intendto infant feed with breastmilk on how to minimize the risk of transmission, including:

• Breastmilk expression with a manual or electric breast pump. This includes the importance of proper hand hygiene before touching any pump or bottle parts and following recommendations for proper pump cleaning after each use. If possible, individuals should consider having someone who does not have suspected or confirmed COVID-19 infection and is not sick feed the expressed breastmilk to the infant. Additionally, individuals should be counseled on whether the facility is able to provide a dedicated breast pump.
• A mother with suspected or confirmed COVID-19 who wishes to breastfeed her infant directly should take all possible precautions to avoid spreading the virus to her infant, including hand hygiene and wearing a mask or cloth face covering, if possible, while breastfeeding. 
• Even in the setting of the COVID-19 pandemic, obstetrician–gynecologists and other maternal care practitioners should support each woman’s informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant. 

4. Healthcare Workers Guidelines

Personal protective equipment (PPE) recommended by the Centers for Disease Control and Prevention (CDC) is listed below, and CDC provides strategies for how to optimize the supply of PPE. ACOG and SMFM have also made statements regarding the urgent need for PPE in obstetrics. 

• To protect patients and coworkers, all healthcare personnel should wear a facemask at all times while they are in a healthcare facility, regardless if patients are wearing a face covering or facemask. Recent data suggests that universal masking, appropriate use of N95 respirators, and close evaluation of extended use or reuse of N-95 respirators in the healthcare setting can play a crucial role in decreasing healthcare-related COVID-19 infections. 
• In areas with moderate to substantial community transmission, healthcare personnel should also wear eye protection in addition to their facemask.
• In areas where universal testing is not employed and adequate PPE is available, universal PPE, including respirators (eg, N95 respirators) is recommended until the patient’s status is known.
• Importantly, all medical staff should be trained in and adhere to proper donning and doffing of PPE. 
• Although there is understandable emphasis on facial protection, data from the SARS outbreak suggest that the comprehensive array of recommended PPE used alongside hand hygiene and environmental cleaning leads to the optimal decreased risk of transmission of respiratory viruses, and this is likely true for COVID-19. 
• During a possible N95 shortage, extended use or limited reuse of N95 masks may be implemented or necessary. If extended use or limited reuse is being implemented, polices regarding extended use or limited reuse should be in accordance with CDC/NIOSHrecommendations, taking into account the actual masks being used. These policies should also be developed in coordination with local occupational health and infection control departments.
• Although limited data have noted subtle physiologic changes associated with extended wear of N95 masks, the reduction of infectious risk outweighs any theoretical physiologic concern.

5. Caring For Individuals With Potential Or Confirmed COVID-19

CDC Recommended Personal Protective Equipment:

• Respirator or Facemask (cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or in other situations where a respirator or facemask is warranted)
• Put on a respirator or facemask (if a respirator is not available) before entry into the patient’s room or care area
• N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure. Disposable respirators and facemasks should be removed and discarded after exiting the patient’s room or care area and closing the door. Perform hand hygiene after discarding the respirator or facemask.
• If reusable respirators are used, they must be cleaned and disinfected according to manufacturer’s reprocessing instructions before re-use.
• When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19.
• Eye Protection
• Put on eye protection (ie, goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient’s room or care area. Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
• Remove eye protection before leaving the patient’s room or care area.
• Reusable eye protection (eg, goggles) must be cleaned and disinfected according to manufacturer’s reprocessing instructions before re-use.
• Disposable eye protection should be discarded after use.
• Gloves
• Put on clean, nonsterile gloves upon entry into the patient’s room or care area.
• Change gloves if they become torn or heavily contaminated.
• Remove and discard gloves when leaving the patient’s room or care area, and immediately perform hand hygiene.
• Gown
• Put on a clean isolation gown upon entry into the patient’s room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient’s room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.
• If there are shortages of gowns, they should be prioritized for:
• Aerosol-generating procedures
• Care activities where splashes and sprays are anticipated
• High-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of the health care practitioner. Examples include:
• Dressing
• Bathing/showering
• Transferring
• Providing hygiene
• Changing linens
• Changing briefs or assisting with toileting
• Device care or use
• Wound care

These are some of the highlights that may pertain to clinicians working with this population. More guidelines as well as future updates can be located in the ACOG website under “practice advisory”. As is true with all aspects of patient care it is important to check guidelines and announcements frequently in order to ensure you are following the most updated information.

Kristen Digwood, DPT, CLT

Elite Pelvic Rehab

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Wilkes-Barre, PA 18702

Phone: 570-970-0402

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