Management of pregnancy during Corona pandemic : The Lancet Analysis

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Since December 2019, the outbreak of coronavirus disease 2019 (COVID-19), 
which originated in Wuhan, China, has become a global public health threat. On Feb 28, 2020, WHO upgraded their assessment of the risk of spread and the risk of impact COVID-19 to very high at global level. By March 28, 2020, 614,884  cases have been reported globally, causing 28,687 deaths The epidemic has spread to 195  countries approx. around the world.

With immunocompromised status and physiological adaptive changes during 
pregnancy, pregnant women could be more susceptible to COVID-19 infection 
than general population. When a person is immunocompromised (sometimes 
referred to as immunosuppressed), it means their immune defenses are weakened and not functioning normally. Physiological adaptive changes include changes in which a woman’s body undergoes to carry the growing fetus.

As COVID-19 is rapidly spreading, maternal management and fetal safety 
become a major concern, but there is scarce information of assessment and 
management of pregnant women infected with COVID-19, and the potential risk of vertical transmission (from mother to fetus) is unclear.

In The Lancet Infectious Diseases (A top infectious diseases journal), Nan Yu 
and colleagues report the clinical features and obstetric and neonatal (first month after baby is born) outcomes of pregnancy with COVID-19 pneumonia in Wuhan, China. Seven pregnant women with COVID-19 pneumonia were assessed and the 
onset symptoms were similar to those reported in non-pregnant adults with 
COVID-19 pneumonia. All patients received oxygen therapy and antiviral 
treatment in isolation. All patients had Caesarean (C -Section) after consultation with a multidisciplinary team and the outcomes of the pregnant women and neonates (new born babies) were good. Three neonates were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and one was found to be infected with COVID-19 36 hours after birth. The findings of the study provide some indications for clinical assessment and management of pregnant women with COVID-19, but questions remain on how to manage pregnant women infected with COVID-19.

As Yu and colleagues reported, five pregnant women were treated with steroids after C-Section. Two were also treated with traditional Chinese medicine.

However, no reliable evidence recommends any specific COVID-19 treatment for pregnant women. WHO guidance and some clinical evidence does not recommend the use of corticosteroids for COVID-19. Use of drugs in pregnant women needs to be on the basis of solid evidence. Clinical trials are needed to prove the effectiveness of drugs and the effects on the fetus to establish a standardized treatment for pregnant women with COVID-19. More evidence of 
the safety of traditional Chinese medicine is also warranted.

The time of delivery in the study was 37 weeks to 41 weeks plus 5 days, all by 
C- Section. In cases of pregnant women with COVID-19, more evidence is 
needed to establish when to deliver and when C-Section should be recommended. 

Previous treatment experience has been inconclusive about which delivery 
method is safer in this patient population. Zhu and colleagues reported nine pregnant women with COVID-19. Seven of the women delivered their babies by C-Section and two by vaginal delivery. All three 
neonates delivered vaginally (including two who were twins) had an Apgar score of at least 9 (the higher the score on scale of 1 to 10, the better the health of newborn) and negative nucleic acid test. A nucleic acid test is a technique used to detect a particular nucleic acid sequence and thus usually to detect a particular virus or bacteria that acts as a pathogen in blood, tissue, urine etc.
Yudin and colleagues reported a pregnant woman with SARS at 31 weeks of gestation; the patient stayed for 21 days in the hospital and did not require 
intensive care admission or ventilator support, and a healthy baby girl was 
delivered by vaginal birth. It is unknown whether vaginal delivery increases the 
infection risk. Further research is needed to assess the risk and to produce guidelines for delivery times and methods in patients with COVID-19.
As discussed in study, although all mothers and infants showed good outcomes, all enrolled pregnant women were in the third trimester, and all had only mild symptoms. Hence, the effect of SARS-CoV-2 infection on the fetus in the first and second trimester or in patients with moderate to severe infection is unknown.

As a previous study reported, SARS coronavirus infection during pregnancy 
might cause preterm birth, intrauterine growth restriction, intrauterine death and neonatal death. Considering that the potential of SARS-CoV-2 to cause severe obstetric and neonatal adverse outcome is unknown, rigorous screening of suspected cases during pregnancy and long-term follow-up of confirmed mothers and their neonates are needed.

In the study by Yu and colleagues, three neonates were tested for SARC-CoV-2, 
of whom two were negative. One neonate was positive, but the viral nucleic acid tests of the placenta and cord blood in this case were negative. At the end of follow-up, no pneumonia and other clinical symptoms and signs were reported.

Reference : With inputs from  The Lancet Infectious Disease 2020.


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