COVID-19 Questions and Answers

There is evidence, for example, that the Delta variant is more infectious. In general, the data in non-pregnant adults are similar to the data in pregnancy. The important thing is that the vaccine covers these different variants so far, as far as far as we know, so it is really important to give the vaccine to women. Only about 35%* of pregnant women have been vaccinated, and that needs to increase. However, there is also safety data on over 250,000* women in the US reported to the CDC. So, there are different strains that can affect women a little bit differently in terms of infections, but the vaccines cover [them]. Also, I really need to emphasize the need for women to get vaccinated as soon as they can get a handle on the vaccine. In fact, in the US, they should even get boosters because some US and other women have been vaccinated six or more months ago.
Dr Vincenzo Berghella
* Data correct as at 2 Dec, 2021
 

It really depends mostly on the viremia. And the viremia – so, that the virus in the blood of the mother – depends on how sick she is. So in general, the chance that there is a virus in the blood of the woman is 1% or less. In those cases, if you have a symptomatic mild disease, the chances that the baby gets it is extremely small. If the woman gets really sick – she is critically ill, intubated in the ICU, she has pneumonia – then she has a 30% or higher chance that the virus is in the blood, and that there is viremia. Those are the cases in general that have been reported rarely to have transmission through the placenta to the baby. There are receptors in the placenta, the virus can accept that and go to the baby. But again, there are very few reports; it does exist, but those babies actually did well. So in the rare, very sick woman who passes the virus to the baby, those babies did well anyway.

The neonatologist will normally do a throat swab if there's a COVID positive woman which should be done right away after birth, without delay, as the mother may have transmitted their COVID virus after birth. Then you can do cord blood antibodies and there are some reports with IgM antibodies found in the newborn, and finding that would confirm that transmission. You could look at the amniotic fluid and there are very few reports of positive amniotic fluid. So, these few reports need to have better confirmation – the nasal swab after birth by itself is not enough for me, because there could be contamination. But you could also study amniotic fluid, cord blood, placenta, and other ways to prove the transmission, and there are a handful of good reports like those.
Dr Vincenzo Berghella
 

We have arrived at evidence of a link between COVID-19 and preeclampsia which is compelling and this has been illustrated by the analysis by Professor Romero. It is not just an association between preeclampsia and COVID, but also response relationships. Women who have severe COVID are more likely to develop preeclampsia compared to those who have mild or asymptomatic COVID. For the angiogenic marker, certainly it would be helpful in differentiating between COVID and preeclampsia, because you would expect in preeclampsia that the escalated one level will be increased and the placental growth factor would be reduced. 

But what about if we don't have access to the angiogenic markers? In this case, we can rely on other clues. So, for example, if the woman has respiratory symptoms or fever, that would be more consistent with the diagnosis of COVID. If she has the virus, you can also use imaging; for example, lung ultrasound or lung CT scan, where you would expect to see features of COVID compared to if she has preeclampsia. 

Of course, preeclampsia does not get better until you deliver the baby, while COVID, in the majority of the cases, you would expect to get better with the right support and treatment. But ultimately, you would have to treat the patient in front of you. So if she has hypertension, you need to give antihypertensive treatment; if she has a respiratory compromise, you need to give respiratory support.
Prof Asma Khalil

If you look at the literature, you can see clearly the vast majority of the benefits and also on the data related to the potential safety concerns, referred to the mRNA vaccines, which are basically Pfizer and Moderna. Looking at the available literature, if we have to choose, we would opt for either of these two vaccines. Of course, we have four options, so if a patient had the Johnson & Johnson vaccine, that's fine. If the patient has already had a first dose of the AstraZeneca vaccine, she can have the second dose; there is no reason why she shouldn't do this. But if we can choose, Pfizer or Moderna are the best options based on the available evidence.
Prof Andrea Dall'Asta
 

We already know that the antibodies pass through the placenta to the to the fetus, specifically IGA, and that is very important. When [the baby is] born, the mother passes IGA to the to the neonate through milk. But it has also been suggested that, after several months, people will need a booster vaccine because the antibodies will decrease through time. However, does the booster vaccine protect the unborn baby? Then no, because probably due to the very low vertical transmission that we know, we still don't know the consequences to the unborn baby. Will it protect the baby after it is born? Probably yes, but the mother will pass IGA to the fetus.
Dr Raigam Jafet Martínez Portilla
 

Firstly, the mRNA cannot work itself into our DNA or the baby's DNA, so there is no risk of altering the genes of a baby or a mother. This is very important because often on social media, there is a lot about making genetic changes to the code of the mother and baby, and that simply is not the case. The second is that the mRNA gets into a cell and instructs the cell to produce lots of, for instance, the spike protein of the virus. So, it is just really asking us how to produce lots of material that becomes immunogenic and stimulates an immune response, and the mRNA does not cross the placenta. So on all those counts, vaccines are safe, they don't affect the genetic code of mother and baby and they are very unlikely to affect anything in respect of the baby. 
Prof Christoph Lees
 

Data not granular enough to answer this at present – source. 

ESC Council on Hypertension says ACE-I and ARBs do not increase COVID-19 mortality - source. 

Anyone with COVID-19 should continue to take any medication they are already taking, unless they are told not to by a healthcare professional.  This includes anti-inflammatories (NSAID) such as ibuprofen, naproxen or diclofenac - source. 

We don't know of any data yet. Would need expert consensus.

We don't know of any studies which can differentiate the effect of different antihypertensives on morbidity and mortality in patients with hypertension and COVID. For ISUOG interim guidance click here. For RCOG guidance click here. 

For preterm cases requiring delivery, we urge caution regarding the use of antenatal steroids  for fetal lung maturation in a critically ill patient, because this can potentially worsen the clinical condition, based on data from MERS, and the administration of antenatal steroids would delay the delivery that is necessary for management of the patient.

If antiviral treatment is to be considered, this should be done following careful discussion with virologists. 

For preterm cases requiring delivery, we urge caution regarding the use of antenatal steroids  for fetal lung maturation in a critically ill patient, because this can potentially worsen the clinical condition, based on data from MERS, and the administration of antenatal steroids would delay the delivery that is necessary for management of the patient.

Data limited as yet, see UoG source.

See more information for healthcare professionals regarding this subject here. 

See more information for healthcare professionals regarding this subject here.

See more information on this subject here.

Indication for delivery not always given. About a third of cases showed fetal distress. 

For the moment information on this subject is limited. We suggest looking through the ISUOG interim guidance and RCOG guidance. 

Please see link for review published today. Serious morbidity and preterm delivery evident.

We may need to answer this at the next webinar.

Based on limited data, there is no evidence that vaginal delivery increases the risk of vertical transmission. However, I would not recommend FSE in the event of suboptimal CTG. Prompt delivery by Caesarean section is preferred.

We will have to wait for clinical details to be made public by the NHS.

This is to reduce the exposure of baby to the confirmed/probable/suspected COVID-19 mother as the distance of separation would be less than 1 meter. 

COVID-19 infection itself is not an indication for delivery, unless there is a need to improve maternal oxygenation. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the patient, gestational age and fetal condition. In the event that an infected woman has spontaneous onset of labor with optimal progress, she could be allowed to deliver vaginally. Shortening the second stage by operative vaginal delivery can be considered. 

COVID-19 infection itself is not an indication for delivery, unless there is a need to improve maternal oxygenation. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the patient, gestational age and fetal condition. In the event that an infected woman has spontaneous onset of labor with optimal progress, she could be allowed to deliver vaginally. Shortening the second stage by operative vaginal delivery can be considered. 

Depends on the level of suspicion, if highly suspected, consider doing the COVID test first. Our turn-around time is a few hours. During that period, an AIIR room is needed. Once the woman is screened negative, she can be downgraded. All our women will be given surgical masks in the ward.

Please refer to ISUOG interim guidance for more details: Regarding neonatal management of suspected, probable and confirmed cases of maternal COVID-19 infection, the umbilical cord should be clamped promptly and the neonate should be transferred to the resuscitation area for assessment by the attending pediatric team. There is currently insufficient evidence regarding the safety of breastfeeding and the need for mother/baby separation. If the mother is severely or critically ill, separation appears to be the best option, with attempts to express breastmilk in order to maintain milk production. Precautions should be taken for the cleaning of the breast pumps.

This is not the recommendations in other countries.  ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services. Watch this space.

In a severe case of COVID-19, once mother is stabilised, a bedside scan to evaluate fetal growth and AFI can be considered. It is highly likely that this patient will need emergency delivery to improve maternal oxygenation.

Management of COVID-19-infected pregnant women should be undertaken by a multidisciplinary team (obstetricians, maternal–fetal-medicine subspecialists, intensivists, obstetric anaesthetists, midwives, virologists, microbiologists, neonatologists, infectious-disease specialists). You may refer to 2007 Infectious Diseases Society of America/American Thoracic Society criteria for defining severe community-acquired pneumonia.

COVID-19 infection itself is not an indication for TOP/delivery, unless there is a need to improve maternal oxygenation. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the patient, gestational age and fetal condition. 

There is no data re: presence of virus in vaginal secretions. As there is an alternative to GBS screening, i.e. intrapartum prophylactic antibiotics in high risk cases, clinicians can consider avoiding this procedure.

Only if they have acute respiratory symptoms with or without fever.

This is the recommendation of countries in Asia: China, Singapore, HK.

COVID-19 infection itself is not an indication for delivery, unless there is a need to improve maternal oxygenation. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the patient, gestational age and fetal condition. 

Chest imaging, especially CT scan, should be included in the work-up of pregnant women with suspected, probable or confirmed COVID-19 infection.

Yes.

We suggest looking through the ISUOG interim guidance and RCOG guidance.

No, but in ongoing pregnancies after SARS, 2/3 women had FGR.

In my unit, yes, although this is not in the formal WHO or CDC recommendations.

If delivering a confirmed/suspected/probable COVID-19 patient, YES, use an N95 mask as vaginal delivery is a potential aerosolising event and caesarean section also risks exposure to bodily fluids.

An N95 mask needs to be fitted annually to ensure it has a good seal for the individual's face. There are generally 2 broad ways to fit an N95 mask - a qualitative and a quantitative method. You should speak to your occupational health department to assist you with the fitting procedure if you have not been fitted. 

It is still for 8 hours and up to 5 uses. This tip is only to prevent wasting a mask from inadvertent soilage when not in use.

N95 and FFP3 respirators are scarce and precious commodities especially during this pandemic. The CDC recommends that an N95 mask may be used for up to 8 hours either continuously or reused intermittently up to 5 times. However, they need to be discarded after aerosol-generating procedures, contamination with bodily fluid, exposure to patient with infectious disease requiring contact precaution or visible damage or if it becomes difficult to breathe through it. Tips to prolong the use of your respirator: use a cleanable face shield over the respirator to prevent surface contamination; hang used respirators in between uses in designated storage areas or in a breathable container such as a paper bag; minimise cross contamination by ensuring masks do not touch each other when stored and that each mask is clearly labelled with the name of the user.

The duration of use of each FFP3 mask needs to be checked with the manufacturer's information sheet. Review of some of the available FFP3 mask information sheets online show that they can be used for up to 8 hours depending on make and model as well as conditions of use. As mentioned during the webinar, you should discard your respirator (FFP3 or N95) after aerosol generating procedures, contamination with bodily fluids, noticeable damage on the respirator, if it becomes hard to breathe through and if you have been in close contact with a patient who has an infectious disease that requires contact precaution.

Intrapartum fever is a common symptom. On its own, I do not think there is sufficient evidence currently to recommend the use of PPE although high standards of general preventive measures need to be practiced. If your patient has associated acute respiratory symptoms, treat the patient as a suspected case of COVID-19 until proven otherwise, in which case we would recommend use of PPE during her care. 

ISUOG has published "ISUOG Safety Committee Position Statement: The safe performance of scans in obstetrics and gynecology and equipment cleaning in the context of COVID-19" 

The FDA standards do not address the duration of use of surgical masks but has advised that they are intended for single use. Currently, many centres practice the use of a single surgical mask for the duration of the whole day IF the mask is not visibly damaged or soiled when it needs to be discarded. You should also change your mask if breathing through the mask becomes difficult.  

In Singapore, Hong Kong and many parts of East Asia, we recommend wearing a surgical mask in areas of high risk such as hospitals and other clinical areas. 

We recommend using a FFP3 or N95 respirator if attending to a delivery of a confirmed/probable/suspected COVID-19 patient. For all other patients, we recommend the use of a surgical mask as in all other clinical areas. 

No.

Please refer to ISUOG Safety Committee Position Statement:
''The safe performance of scans in obstetrics and gynecology and equipment cleaning in the context of COVID-19" 

Please refer to ISUOG Safety Committee Position Statement:
''The safe performance of scans in obstetrics and gynecology and equipment cleaning in the context of COVID-19" 

Surgical masks, yes. Non-sterile gloves are not yet in our recommendation but good hand hygiene needs to be observed.

At present, a few junior doctors from O&G have been sent to help in A&E which has seen a surge in number of attendances. This situation is similar in other specialties including repatriation of manpower from radiology to A&E. Senior obstetricians and midwives remain in their usual work as there is no reduction in obstetric services in my unit, only reduction of elective gynaecology services.

No.

Yes, as long as they have booked the appointment and screened negative for high risk in TOCC; in HK, all patients and healthcare workers wear appropriate surgical masks. This allows such important services to continue.

I certainly hope not as we expect NICU to be as busy as ever as obstetric workload will be no different than prior to the pandemic. In addition, there may be neonates (newborns or within their 1st year of life) who will be affected by COVID-19 who might need NICU. These nurses are very much needed in NICU and in my experience, they are usually already traditionally understaffed for their workload.

ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services. 

ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services. Watch this space.

We suspended visitors and encouraged limited number of accompanier for patients who attend for clinics. We reduced non-emergency services and avoided crowding. Provide adequate manpower in the triage area and avoid over-crowding. If there is semi-urgent TOCC positive cases, find a designated area to see them and discharge them from clinic as soon as possible. Soiled closing is well tied in appropriate bags during transport.

ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services.

Please refer to ISUOG Safety Committee Position Statement:
''The safe performance of scans in obstetrics and gynecology and equipment cleaning in the context of COVID-19" . ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services.

ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services.

ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services. 

It depends on the severity of COVID-19. Management of COVID-19-infected pregnant women should be undertaken by a multidisciplinary team (obstetricians, maternal–fetal-medicine subspecialists, intensivists, obstetric anesthetists, midwives, virologists, microbiologists, neonatologists, infectious-disease specialists).

For operation, we try to conserve PPE to high risk area of hospital and avoid usage of PPE during intubation and extubation procedure for non-life saving or non-malignancy cases. Therefore, about 50% reduced in elective surgery. For outpatient services, we do not introduce extra work to contact all patients, but about 50% defaulted due to worry to come to hospital. In outpatient clinics, some clinics can be combined to save manpower and resources.

Meanwhile, we need PPE to protect Anaesthetists and the related health care worker during intubation and extubation as these are aerosol generating procedures. Performing surgery under regional anaesthesia may help to conserve the PPE and not an inferior option to patient either. 

No specific guidance for this. UK government guidance on social distancing in vulnerable groups, including pregnancy. 

No, but it may be a useful psychological approach, see video.

This is the subject of ongoing trials, nil published for pregnant women to date.

This hasn't appeared in any national plans to date.

I do not have staff with significant health problem. Priority can be set in the whole organization and each unit with consensus from all colleagues. Generally, staffs who are pregnant or have significant chronic medical problems will have a low priority to be deployed.

If a healthcare worker has had significant unprotected contact with a confirmed  COVID-19  case, we recommend quarantine for 14 days and testing if/when symptomatic. 

We recommend screening and testing healthcare workers in the same criteria as you would with everyone else. Testing facilities need to be made accessible to both the public and especially to healthcare workers to ensure early diagnosis and institution of appropriate infection control measures, including quarantine.