ACEP COVID-19 Field Guide

Author: Aisha T. Terry, MD, MPH, FACEP, Associate Professor of Emergency Medicine and Health Policy, George Washington University School of Medicine and Hospital, American College of Emergency Physicians, Board of Directors Member

Knowledge about the pathophysiology and management of COVID-19 in pregnant women continues to evolve. Based on current data, there is no definite indication that pregnant women are at an increased risk. However, pregnant women with other respiratory infections, such as influenza and SARS-CoV, are at greater risk of severe morbidity and mortality. Thus, pregnant women represent a special population and should be considered an at-risk population for COVID-19. Based on limited data, infants born to COVID-19 infected mothers have experienced adverse outcomes such as preterm birth, but it is unclear as to whether these outcomes were related to maternal infection. It is also currently unclear as to whether COVID-19 crosses the placenta and poses an infectious threat to the newborn. In a limited case series of infants born to COVID-19 positive mothers, none of the newborns tested positive for COVID-19.

As important efforts are made to mitigate the spread of this infection across communities, the unintended impact of limiting prenatal care visits and access must be recognized. Communication plans should be determined in advance to ensure that pregnant women have adequate access to prenatal care and testing, perhaps through telehealth and other virtual mechanisms.

To minimize the spread of infection relative to managing prenatal, natal, and postnatal services, key recommendations published by the CDC should be followed:

• Health care practitioners should promptly notify infection control personnel at their facility of the anticipated arrival of a pregnant patient who has confirmed COVID-19 or is a PUI.
• Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. Airborne Infection Isolation Rooms should be reserved for patients undergoing aerosol-generating procedures.
• Face masks are an acceptable alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols. 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.
• Infants born to mothers with confirmed COVID-19 should be considered PUIs. As such, these infants should be isolated according to the Infection Prevention and Control Guidance for PUIs.
• To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (eg, in separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued.
• Discharge for postpartum women should follow recommendations described in the Interim Considerations for Disposition of Hospitalized Patients with COVID-19.

The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have developed an algorithm to aid practitioners in the “Outpatient Assessment and Management for Pregnant Women With Suspected or Confirmed Novel Coronavirus (COVID-19).” 

Breastfeeding

Based on the limited case series to date, there is no evidence that the virus is found in the breast milk of women infected with COVID-19. It is not yet known, however, if COVID-19 can be transmitted through breast milk (ie, infectious virus in the breast milk). In terms of breastfeeding, the primary concern is that a COVID-19 infected mother could transmit the infection to the infant through respiratory droplets while breastfeeding. A mother with confirmed COVID-19 infection or who is a PUI should take every precaution to prevent such spread, by wearing a face mask and washing her hands with soap and water for at least 20 seconds before touching the infant or any pump or bottle parts during the process of feeding. If possible, the mother should strongly consider having someone who is well feed expressed breast milk to the infant.

Pregnant health care workers

Pregnant health care personnel should follow published CDC recommendations of standard, contact, and airborne precautions when managing patients with or suspected of having COVID-19. These workers should follow risk assessment and infection control guidelines for health care personnel exposed to patients with suspected or confirmed COVID-19. Facilities may consider inviting pregnant health care workers to limit their potential exposure, particularly during high-risk procedures, such as aerosol-generating procedures, by adjusting staffing models as feasible.

References

1. American College of Obstetricians and Gynecologists. Novel coronavirus 2019 (COVID-19) practice advisory. ACOG website. 2020 Mar.
2. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records [published correction appears in Lancet. 2020 Mar 28;395(10229):1038]. Lancet. 2020;395(10226):809-815. doi:10.1016/S0140-6736(20)30360-3