NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date. This entry has been updated with the recommendations for COVID-19 vaccination during pregnancy

SUMMARY:

The recent outbreak of the novel coronavirus, now called SARS-CoV-2, and spread of COVID-19 infection 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 with key highlights – the full CDC recommendations can be found at the Obstetric Healthcare Settings page (find link below in ‘Learn More – Primary Sources’ as well as link to ACOG Practice Advisory)  

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
  • 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 

• Mother is breastfeeding
  • Wash her 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

• An mRNA vaccine that encodes a SARS-CoV-2 full-length spike protein has been released under FDA Emergency Use Authorization
• Two doses of BNT162b2 spaced 21 days apart conferred 95% protection against COVID-19 in people aged 16 and over with a safety profile similar to other vaccines
• Pregnant and lactating women were excluded from the studies

FDA

• FDA does not specifically advise against use in pregnancy or lactation but rather notes lack of data

All pregnancies have a risk of birth defect, loss, or other adverse outcomes. In the US general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively

Available data on Pfizer-BioNTech COVID-19 Vaccine administered to pregnant women are insufficient to inform vaccine-associated risks in pregnancy

Data are not available to assess the effects of Pfizer-BioNTech COVID-19 Vaccine on the breastfed infant or on milk production/excretion

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) 

• There is insufficient evidence to recommend the routine use COVID-19 vaccines during pregnancy
• Women who are considered “clinically extremely vulnerable” should discuss COVID-19 vaccination with a physician | Clinical scenarios include
  • Solid organ transplant recipients
  • Severe respiratory, renal or cardiac conditions
  • Homozygous sickle cell disease
  • Immunocompromised
• Frontline health or social care workers
  • Can also discuss the option of vaccination due to significant exposure risk
• 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

• There is an absence of evidence-informed recommendations upon which to base guidelines related to COVID-19 vaccine during pregnancy and lactation
• The SOGC states that

For individuals who are at high risk of infection and/or morbidity from COVID-19, it is the SOGC’s position that the documented risk of not getting the COVID-19 vaccine outweighs the theorized and undescribed risk of being vaccinated during pregnancy or while breastfeeding and vaccination should be offered

For an individual planning a pregnancy, it is recommended to complete the entire COVID-19 vaccination series (where possible) to achieve maximal vaccine efficacy ahead of pregnancy

It is not known whether an individual should delay pregnancy following receipt of the vaccine and a risk-benefit discussion for those planning pregnancy should occur similar to the discussion for pregnant and breastfeeding women

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: People who are at higher risk for severe illness

CDC: Considerations for Inpatient Obstetric Healthcare Settings

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

CDC: Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19

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

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

ACOG: Vaccinating Pregnant and Lactating Patients Against COVID-19

ASRM UPDATE No. 11 – COVID-19 Vaccination

RCOG: Updated JCVI advice on COVID-19 vaccination in pregnancy and women who are breastfeeding

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

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?

A case of 2019 Novel Coronavirus in a pregnant woman with preterm delivery

Related ObG Topics: