NOTE: CDC has updated guidance and specifies that special breastfeeding precautions are not required for women who are vaccinated. Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date.

SUMMARY:

The spread of COVID-19 is being closely monitored worldwide. The following provides key highlights from major professional organizations along with valuable links to other resource hubs focused on COVID-19 and pregnancy  

• Presentation in Pregnancy
• CDC: Obstetric L&D Recommendations
• Vaccination During Pregnancy and Lactation
• ACOG Practice Advisory
• SMFM Guidance
• ASRM Guidelines – Fertility Health
• RCOG Guidelines

COVID-19 Presentation in Pregnancy

• Presentation and clinical findings for COVID-19 pneumonia do not differentiate in pregnant women vs the general population
• Typical presentation with COVID-19 includes
  • Common clinical features: Fever | Fatigue | Dry cough
  • Lymphopenia (<1.0 × 10⁹ cells per L)
  • Myalgia
  • Sore throat
• Reports of
  • Liver involvement (elevated transaminases, coagulopathies) and decreased platelets
  • Cardiac injury biomarkers
  • Loss of smell and taste
  • Conjunctivitis
• Pregnant women are in the “increased risk” CDC category
  • Data suggests that pregnant women with COVID-19 may be at higher risk for mechanical ventilation, ICU admission and mortality vs symptomatic non-pregnant women
  • CDC acknowledge a significant study limitation related to missing data
  • Similar to non-pregnant women, increased adverse outcomes are seen in women with comorbidities.
  • ACOG reiterates the CDC findings and states that

Although these data from the CDC suggest 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

CDC: Obstetric L&D Recommendations

The following is a summary of precautions related to pregnant women with suspected or confirmed COVID-19 |  The full CDC recommendations can be found at the CDC: Considerations for Inpatient Obstetric Healthcare Settings page (find link below in ‘Learn More – Primary Sources’)  

Visitors

• Visitors should be limited to those required for emotional care support, prioritizing maternal well-being
• Depending upon the extent of community-transmission, institutions may consider limiting visitors to one essential support person and having that person be the same individual throughout the hospitalization
• All visitors should be screened and, if cleared, should be educated regarding appropriate transmission prevention measures 
• Visitor screening
  • Visitors should not be allowed entry if fever or respiratory symptoms are present

Mother-Infant Separation: Vertical Transmission and Newborn Risk  

• Current evidence suggests that
  • Risk of a neonate acquiring SARS-CoV-2 from its mother is low
  • No difference in risk of SARS-CoV-2 infection to the neonate whether separated or rooming in
  • There is potential risk of transmission to neonate from contact with infectious respiratory secretions from the mother or others in close contact
• Considerations for discussions between mother and healthcare provides include the following benefits of rooming in
  • Helps mothers learn newborn feeding cues, which helps establish breastfeeding
  • Bonding is facilitated
  • Promotes family-centered care and can allow for parent education
• Discontinuation criteria
  • Mothers who have met discontinuation criteria should not be considered as posing a potential risk of virus transmission 
  • Mothers who have not met discontinuation criteria: May choose to temporarily separate from their neonates | However, unclear whether temporary separation in hospital will prevent transmission to neonate if after discharge they will not be able to maintain separation
• When to consider separation
  • Mothers who are too ill to care for their infants or who need higher levels of care
  • Neonates at higher risk for severe illness (e.g., preterm infants, infants with underlying medical conditions, infants needing higher levels of care)
• If a newborn tests positive for SARS-CoV-2

Separation in order to reduce the risk of transmission from a mother with suspected or confirmed SARS-CoV-2 to her neonate may not be necessary

• • •  

Infection Controls if No Separation 

• Consider using the following controls
  • Physical barriers (e.g., a curtain between the mother and newborn)
  • Keeping the newborn ≥6 feet away from the ill mother
  • Mother (with confirmed COVID-19 or PUI) should use a cloth face covering and practice hand hygiene before each feeding or other close contact with her newborn | Keep face covering in place during contact 

Breastfeeding when Mother has Suspected or Confirmed COVID-19 

• Breast milk is not a likely source of infection 
• According to the CDC, special breastfeeding precautions are not necessary for the following
  • People without suspected or confirmed COVID-19 and who have not been in close contact with someone who has COVID-19 or 
  • who have received the COVID-19 vaccine  
• If mother has suspected or confirmed COVID-19 or has been in close contact with someone with COVID-19 and is not full vaccinated, counsel the following 
  • Wash hands using soap and water before touching the infant or use hand sanitizer (at least 60% alcohol) if soap unavailable
  • wear a cloth face covering while feeding at the breast
• Mother is expressing
  • Clean hands as above before touching any pump or bottle parts
  • Wear a cloth face covering
  • If possible, expressed breast milk should be fed to the infant by a healthy caregiver, who is not at high-risk for severe illness from COVID-19

Discharge Planning  

• Patients with COVID-19 can be discharged from the healthcare facility whenever clinically indicated
•  Meeting criteria for discontinuation of Transmission-Based Precautions is not a prerequisite for discharge

Note: CDC defines hand hygiene as follows 

Hand hygiene includes use of alcohol-based hand sanitizer that contains 60% to 95% alcohol before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. Hand hygiene can also be performed by washing with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to alcohol-based hand sanitizer.

Vaccination in Pregnancy and During Lactation

• Vaccines have been released in the US under FDA Emergency Use Authorization, offering significant protection against COVID-19 (particularly higher severity disease requiring hospitalization)
• Pregnant and lactating women were excluded from the initial studies, although research including pregnant women and children are currently ongoing

CDC

• The CDC has updated its guidelines and now recommends that pregnant women be offered COVID-19 vaccine
• While speaking with a healthcare professional may be helpful, it is not required
• Trials are ongoing, but data from the V-safe registry did not detect any obvious safety signals with respect to pregnancy or neonatal outcomes
• While the CDC states that risk of severe illness during pregnancy is still low, pregnant women are considered a high risk group due to increased risk for severe illness

Severe illness includes illness that results in intensive care admission, mechanical ventilation, or death

Additionally, pregnant people with COVID-19 might be at increased risk of adverse pregnancy outcomes, such as preterm birth, compared with pregnant women without COVID-19

ACOG

• ACOG, in the practice bulletin on this topic, does not recommend a pregnancy test as a requirement prior to vaccination and furthermore states that

…COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on ACIP-recommended priority groups

COVID-19 vaccines should be offered to lactating individuals similar to non-lactating individuals when they meet criteria for receipt of the vaccine based on prioritization groups outlined by the ACIP

SMFM

• SMFM, along with many other medical professional societies, strongly encourages the inclusion of pregnant and lactating women in vaccine trials if certain criteria are met
  • Pregnancy increases risk for susceptibility or severity
  • Best approach to protect the infant is through passive placental antibody transfer
  • An active outbreak is present
• Currently, women have been excluded from COVID-19 trials and SMFM states that “the existing practice of “protection by exclusion is harmful”
• In addition, SMFM states

In general, SMFM strongly recommends that pregnant women have access to COVID-19 vaccines in all phases of future vaccine campaigns, and that she and her healthcare professional engage in shared decision-making regarding her receipt of the vaccine

Healthcare professionals should also counsel their patients that the theoretical risk of fetal harm from mRNA vaccines is very low

SMFM recommends that healthcare workers, who are considered prioritized for vaccination, be offered the vaccine if pregnant

ASRM

• The ASRM, aligned with other US women’s health organizations, does not recommend withholding the vaccine from patients who pregnant, breastfeeding or planning to conceive
• In addition

Patients undergoing fertility treatment and pregnant patients should be encouraged to receive vaccination based on eligibility criteria

Patients who conceive in the window between the first and second dose of the vaccine should be offered the second dose of the vaccine at the appropriate interval

Available data indicate that COVID-19 vaccines do not cause infertility in women or men

In the randomized blinded Pfizer-BioNTech trial, a similar number of women conceived after receiving the vaccine as those who received the placebo

UK Joint Committee on Vaccination and Immunisation (JCVI) 

• Pregnant women should be offered the COVID-19 vaccine at the same time as the rest of the population, based on their age and clinical risk group
• “There have been no specific safety concerns from any brand of COVID-19 vaccines in relation to pregnancy” although because there is more ‘real world’ safety data for mRNA vaccines, JCVI advise a preference for Moderna and Pfizer-BioNTech
• Breastfeeding
  • No known risk and therefore women who are breastfeeding should be offered vaccination if they are eligible
• Routine pregnancy testing is not required prior to vaccination
• Those who are trying to become pregnant do not need to avoid pregnancy after vaccination

SOGC

• The SOGC states “Women who are pregnant or breastfeeding should be offered vaccination at any time during pregnancy if they are eligible and no contraindications exist”

This decision is based on the women’s personal values and an understanding that the risk of infection and/or
morbidity from COVID-19 outweighs the theorized and undescribed risk of being vaccinated during pregnancy or while breast feeding

Women should not be precluded from vaccination based on pregnancy status or breastfeeding

WHO

While pregnancy puts women at higher risk of severe COVID-19, very little data are available to assess vaccine safety in pregnancy.

Nevertheless, based on what we know about this kind of vaccine, we don’t have any specific reason to believe there will be specific risks that would outweigh the benefits of vaccination for pregnant women.

For this reason, those pregnant women at high risk of exposure to SARS-CoV-2 (e.g. health workers) or who have comorbidities which add to their risk of severe disease, may be vaccinated in consultation with their health care provider

KEY POINTS:

ACOG Practice Advisory

• ACOG has released a practice advisory, providing guidance and valuable links
• Based on prior experience with significant viral infections, diligence is warranted in the management of pregnant women during the COVID-19 pandemic
• Testing on labor and delivery
  • Women with suspected COVID-19 or those who develop related symptoms “should be prioritized for testing”
  • Universal testing: Consider molecular testing strategies to identify asymptomatic patients, particularly in high prevalence areas
  • PPE: ACOG reviews CDC guidance
    • Respirators (e.g., N95 respirators) should be used when caring for patients with confirmed or suspected COVID-19
    • Aerosol-generating procedures should be prioritized during shortages
    • ACOG restates the CDC opinion that second stage is not considered an aerosol-generating procedure and adds the following

ACOG continues to review questions and data regarding the potential for aerosolization in the context of forceful exhalation during the second stage of labor 

• Mother-infant separation
  • ACOG recognizes that multiple organizations do not recommend this separation
  • ACOG states that because evidence is limited, “the determination of whether to keep patients with known or suspected COVID-19 and their infants together or to separate after birth should be made on a case-by-case basis, using shared decision-making”
• ACOG and SMFM provide an algorithm to aid in the assessment and management of pregnant women with suspected or confirmed COVID-19

Tap Image to Open Algorithm

SMFM Guidance

• SMFM has released multiple documents addressing obstetrical management (see ‘Learn More – Primary Sources’ below)

Fetal Surveillance and Management

In the setting of a mild infection, management similar to that for a patient recovering from influenza is reasonable. Given how little is known about this infection, a detailed midtrimester anatomy ultrasound examination may be considered following first-trimester maternal infection.

For those experiencing illness later in pregnancy, it is reasonable to consider sonographic assessment of fetal growth in the third trimester

Delivery Planning for Mildly Symptomatic or Asymptomatic Pregnant Patients

• COVID-19-positive status is not an indication for delivery
  • Timing and mode of delivery should be based on usual obstetrical indications
• 37w0d to 38w6d: To limit exposure of healthcare team and neonate (and reduce PPE utilization were supply is limited) consider expectant management until
  • 14 days after the positive SARS-CoV-2 test result or
  • until 7 days after onset of symptoms and 3 days after resolution of symptoms
• ≥39 weeks
  • Consider delivery to reduce risk of worsening maternal status

Delivery for Patients Who are Critically Ill

• SMFM provides guidance on management of critically ill women who are pregnant
• Care needs to be individualized and addition, the document states that

Although data regarding delivery timing and acute respiratory distress syndrome are limited, it is reasonable to consider delivery in the setting of worsening critical illness

ASRM Guidelines – Fertility Health

• Fertility services are considered an essential health service
• “Baseline PCR testing for COVID-19 should be encouraged prior to starting any type of fertility treatment and prior to surgical interventions”
• ASRM also considers it ‘prudent’ to encourage patients who test negative for COVID-19 to self quarantine during treatment and into early pregnancy
• The impact of the pandemic varies across the country and if certain parameters are met (e.g., sustained reduction in cases), practices can consider resuming care
• The updated guidance provides required standards that should be met prior to reinstating practices, as well as recommendations regarding office practice (see ‘Learn More – Primary Sources’ for ASRM documents and updates)

COVID-19 Screening and Donor Programs

• Oocyte donors
  • Consider incorporating additional counseling and documentation regarding screening
  • Consider cancelling if the donor has a positive SARS-CoV-2 test or develops COVID-19 during ovarian stimulation
  • FDA
    • Does not recommend SARS-CoV-2 testing prior to obtaining oocytes for third-party reproduction
    • Does recommend using screening questions
• Sperm donors
  • SARS-CoV-2 may be present in semen
  • Quarantine of donor sperm
    • Anonymous: 6 month quarantine (FDA requirement)
    • Directed donation: Quarantine not required by but may be considered at the discretion of the recipient and physician
  • FDA
    • Does not recommend SARS-CoV-2 testing prior to obtaining oocytes for third-party reproduction
    • Does recommend using screening questions

Educational Responsibilities

• In addition, ASRM makes the case that the professional community should be proactive and deliberately address misinformation with patients

Providers should proactively and deliberately encourage patients to ask questions regarding COVID-19 and the pandemic throughout their treatment and may wish to counsel patients on reliable sources of information

RCOG Guidelines

• Guidance for healthcare professionals on Coronavirus (COVID-19) infection in pregnancy has been published by the RCOG, Royal College of Midwives, Royal College of Paediatrics and Child Health, Public Health England and Health Protection Scotland
• Effects on mothers and fetuses sections updated due to UKOSS registry results of hospitalized pregnant women (see ‘Related ObG Topics’ below for review of the UKOSS data)

Effect on Pregnant Women

• Of the 427 pregnant women in the UKOSS registry
  • Level 3 care: 9% of women
  • ECMO: <1% (4 women)
  • Case fatality rate: 1.2% (95% CI, 0.4 to 2.7%)
  • Represents a SARS-CoV-2 associated maternal mortality rate of 5.6 (95% CI, 1.8 to 13.1) per 100,000 maternities

Effects on Fetus and Neonate

• “No data suggesting an increased risk of miscarriage or early pregnancy loss in relation to COVID-19” | Current data not sufficiently convincing to make the association
• UKOSS cohort
  • Median gestational age at birth: 38 weeks (IQR 36–39 weeks)
  • Preterm birth rate: 27% | 47% of these were iatrogenic for maternal compromise | 15% were iatrogenic for fetal compromise
  • NICU admission: 10%
  • Positive SARS-CoV-2 test: 2.5% (6 infants) during the first 12 hours after birth (included some infants that were delivered by cesarean without labor)
  • Fetal and newborn loss
    • 3 stillbirths (2 unclear if related to COVID-19)
    • 2 neonatal deaths (definitely not related to COVID-19)

Pregnant Healthcare Workers

• While ACOG advises that “Health care facilities may consider limiting exposure of pregnant health care personnel to patients with confirmed or suspected COVID-19 infection, especially during higher risks procedures”, RCOG recommends the following

Choices for pregnant healthcare workers prior to 28 weeks’ gestation: Following a risk assessment with their employer and occupational health, pregnant women should only be supported to continue working if the risk assessment advises that it is safe for them to do so. This means that employers must remove any risks (that are greater in the workplace than to what they would be exposed to outside of the workplace), or else they should be offered suitable alternative work

For pregnant women from 28 weeks’ gestation, or with underlying health conditions such as heart or lung disease at any gestation, a more precautionary approach is advised. Women in this category should be recommended to stay at home. For many healthcare workers, this may present opportunities to work flexibly from home in a different capacity, for example by undertaking telephone or videoconference consultations, or taking on administrative duties

Note: Find additional international professional guidelines below in ‘Learn More – Primary Sources’

Learn More – Primary Sources:

CDC: Information for Healthcare Providers: COVID-19

CDC: Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19)

CDC: Considerations for Inpatient Obstetric Healthcare Settings

CDC: Evaluation and Management Considerations for Neonates At Risk for COVID-19

CDC: Discontinuation of Transmission-Based Precautions and Disposition of Patients with SARS-CoV-2 Infection in Healthcare Settings

ACOG: Practice Advisory: Novel Coronavirus 2019 (COVID-19)

ACOG: COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics

CDC: Information about COVID-19 Vaccines for People who Are Pregnant or Breastfeeding

ACOG: COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care

ASRM UPDATE No. 11 – COVID-19 Vaccination

JCVI issues new advice on COVID-19 vaccination for pregnant women

SOGC Statement on COVID-19 Vaccination in Pregnancy

FDA: Pfizer-BioNTech COVID-19 Vaccine

SMFM: Coronavirus (COVID-19) Resource Page

ASRM: Patient Management and Clinical Recommendations During The Coronavirus (COVID-19) Pandemic

RCOG: Coronavirus (COVID-19) infection and pregnancy

RCOG: Updated advice for pregnant healthcare workers and employers during the coronavirus outbreak

WHO: The Moderna COVID-19 (mRNA-1273) vaccine: what you need to know

The Royal College of Physicians of Ireland: The Institute of Obstetricians and Gynaecologists issues guidance on Covid-19 and maternity services

FIGO: COVID-19 Resources

RANZCOG: Coronavirus (COVID-19) Advice and Information

Collège National des Gynécologues et Obstétriciens Français (CNGOF): Prise En Charge Aux Urgences Maternite D’une Patiente Enceinte  Suspectee Ou Infectee Par Le Coronavirus (Covid-19)

Federação Brasileira das Associações de Ginecologia e Obstetrícia (FEBRASCO): Infecção pelo Coronavírus SARS-CoV-2 em obstetrícia. Enfrentando o desconhecido

SOGC: COVID-19 Resources

ISUOG: COVID-19 Resources

JAMA: What Is a Pandemic?

Related ObG Topics: