Pregnant patients are at increased risk for COVID-19 vs nonpregnant patients. Pregnancy should be considered a ‘high risk category’ (CDC) and should be managed as such. SMFM has updated a document regarding perinatal care that provides valuable information to professionals managing women with COVID-19 during pregnancy as well as helpful counseling tips to encourage vaccination to avoid complications due to infection.
Severe maternal morbidity and mortality from obstetric causes: aRR 12.8 (95% CI, 8.2 to 9.1)
Vaccine Consideration
Vaccines and boosters are recommended for pregnant, postpartum and lactating people to reduce risk for COVID-19 and consequent complications
SMFM and ACOG recommend that pregnant people receive a COVID-19 booster shot at least 6 months after their primary series for mRNA-based vaccines (ie, Pfizer or Moderna) and at least 2 months after their primary vaccination for the Janssen vaccination
As with the primary series, the booster dose can be given at any stage during pregnancy and postpartum
Bivalent booster dose
In addition, SMFM and ACOG support the CDC regarding bivalent boosters that recommends
…all pregnant, recently pregnant, or lactating people receive a bivalent booster, to mitigate increased risk of adverse maternal, fetal, and obstetric outcomes of COVID-19 disease
Additionally, the bivalent booster should be given at any point in pregnancy
Note: Additional information regarding vaccination in pregnancy can be found below in ‘Related ObG Topics’
SARS-CoV-2 Testing
Individuals should undergo viral testing
Immediately for those with COVID-19 symptoms and/or
Within 5 days of known exposure
Test for other causes of respiratory illness such as influenza if clinically appropriate
NIH Recommendations: COVID-19 Therapeutics and Pregnancy
The NIH Panel provides guidance on COVID-19 therapy in patients who are pregnant or lactating and states the following
The COVID-19 Treatment Guidelines Panel (the Panel) recommends against withholding COVID-19 treatments or vaccination from pregnant or lactating individuals specifically because of pregnancy or lactation
In general, the therapeutic management of pregnant patients with COVID-19 should be the same as for nonpregnant patients, with a few exceptions
The Panel recommends against the use of molnupiravir for the treatment of COVID-19 in pregnant patients unless there are no other options and therapy is clearly indicated
There is insufficient evidence for the Panel to recommend either for or against the use of therapeutic anticoagulation in pregnant patients with COVID-19 who do not have evidence of venous thromboembolism
Monoclonal Antibodies in Pregnancy
Use shared decision-making
Acknowledge limitations of current data
Therapies that would otherwise be given should not be withheld specifically due to pregnancy or lactation
Therapies including monoclonal antibodies, remdesivir, dexamethasone, baricitinib, and tocilizumab, can and should be provided to pregnant patients with COVID-19 who meet clinical qualifications
Note: Additional information on use of monoclonal antibodies, including use for postexposure prophylaxis, can be found in the NIH management summary in ‘ObG Project Topics’
Oral Antivirals in Pregnancy
Paxlovid
Following FDA EUA for Paxlovid, SMFM issued a statement in support of the use of this medication in pregnancy for those with mild to moderate COVID-19 at risk for disease progression
SMFM supports the use of Paxlovid (nirmatrelvir [PF-07321332] tablets and ritonavir tablets) for treatment of pregnant patients with COVID-19 who meet clinical qualifications
Any therapy that would otherwise be given should not be withheld specifically due to pregnancy or lactation
Molnupiravir
SMFM addresses the use of molnupiravir and concerns regarding mutagenicity
The NIH Panel states
The Panel recommends against the use of molnupiravir for the treatment of COVID-19 in pregnant patients unless there are no other options and therapy is clearly indicated
Vertical Transmission to Newborns
Evidence suggests a perinatal infection 1% to 4%
More research required to understand risk dynamics (e.g., timing during pregnancy)
Risk for Miscarriage or Congenital Anomalies
Studies have not demonstrated increased risk for miscarriage
Data “insufficient to suggest an increased risk of congenital anomalies associated with SARS-CoV-2 infection early in pregnancy”
Risk for Preterm Birth or Stillbirth
CDC data suggests a potential increase in the risk for stillbirth further supporting the strong recommendation for COVID-19 vaccination during pregnancy
Reports estimate that risk for stillbirth may be 4x
Study performed during Delta wave
Higher severity of illness may be related to increased risk of stillbirth, HDP, preterm birth and cesarean delivery
Note: More information on the CDC data regarding stillbirth and COVID-19 can be found in ‘Related ObG Topics’ below
Obstetric Care Appointments During the Pandemic
Strategies that alter Ob appointments will depend on local circumstances and practice
Telehealth can be used
Antenatal surveillance for high-risk conditions should continue when indicated
COVID-19 and Antenatal Surveillance
Mild infection
Management similar to that of patient recovering from influenza
Be aware that a patient may initially have mild symptoms but decompensate | Instruct patients to call or seek care for worsening symptoms
Consider ultrasound following periconception or first trimester maternal infection
Detailed midtrimester anatomy scan
Interval growth assessments (depending on the timing and severity of infection, and other risk factors)
Data insufficient to recommend fetal surveillance for stillbirth risk
Lactation Considerations
SARS-CoV-2 has not been detected in breast milk
Breastfeeding is not contraindicated
Precautions should be undertaken to avoid transmission to the infant
Hand hygiene
Face covering
Proper pump cleaning
If patient is receiving therapeutic agents for COVID-19, decision to breastfeed
…should be a joint effort between the patient and the clinical team, including infant care providers
KEY POINTS:
When to Deliver
Maternal COVID-19 infection alone “is not an indication for delivery”
Infection in pregnancy with recovery
No change in timing of delivery
Infection at or near term
Individualize balancing risk for maternal deterioration against delivery support services, risk to attending staff re: viremia load
Critically ill patients
Shared decision making
Balance preterm delivery against possible improvement in maternal status
Cesarean delivery does not reduce risk for perinatal infection
Postpartum Care
High transmission area
Telehealth is reasonable
Contraception
Discuss options during prenatal care and make a plan “to facilitate immediate postplacental long-acting reversible contraception utilization if desired”
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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