Pregnancy and Coronavirus Infection (COVID-19)
Coronavirus infection (COVID-19) has gradually spread throughout the world and turned into a pandemic. Its rapid spread, lack of treatment, and being fatal increase the effect of the disease. No increased sensitivity has been reported in pregnant women compared to the general population. However, the subject becomes important due to the fact that pregnant women are more susceptible to diseases than those who are not pregnant, the possible risks are high, and the high mortality rates caused by SARS-CoV and MERS-CoV infections, which are similar viruses, in pregnant women. There is limited information in pregnant women and for now, management is like non-pregnant. Some pregnant women have experienced fetal stress and preterm labor. There is no evidence that it has passed from mother to baby. In pregnancy and childbirth management, isolation under appropriate conditions, detailed infection control management, early mechanical ventilation in progressive respiratory problems, oxygen therapy, avoiding excess fluid treatment, tight fetal follow-up and monitoring come to the fore.
The disease due to coronavirus infection appeared in China in late 2019 and spread to the world. In February 2020, the World Health Organization (WHO) defined the disease as COVID-19, the causative virus as “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)” (2).
The virus is transmitted by droplets emitted by coughing and sneezing from sick individuals and by contact with the patient’s hand, eye, mouth and nasal mucosa from contaminated surfaces (4). It is known that the droplet does not exceed about 2 meters. Contagion has also been reported from individuals who did not produce findings (5). It is believed that the duration of the occurrence of the disease after the first infection is on average 5 days (2-14 days). However, among the recent cases, it has been reported that there are no signs of contact with infected people (6). The average age is 49-56 years and there is additional disease in 1/3 to half of the cases (7).
Common symptoms of infection are respiratory distress, fever, and cough. In severe cases, pneumonia, severe acute respiratory infection, kidney failure, and even death may develop. In suspected cases, the diagnosis is made by testing samples from the lower and / or upper respiratory tract. In cases of high suspicion with a negative first test, the test is repeated. If both qRT-PCR analyzes are negative, COVID-19 is not considered (4). In cases diagnosed with COVID-19, the frosted glass image, which is a typical finding on computed tomography (CT), was observed at 56.4%. No radiological findings were observed in 17.9% of non-severe cases. The drop in blood white spheres was seen in 83.2% of patients. The average length of hospitalization of cases is 12 days (8).
The risk of death is about 2% and may differ depending on the changes in the genetic structure of the virus. There is no vaccine or antiviral treatment for the disease yet (4). There are studies on drugs such as Remdesivir, hydroxychloracine, lopinavir-ritonavir, tocilizumab in treatment (5). However, there is no clear data on the use of these drugs in pregnant women with the diagnosis of COVID-19. Hydroxychloracine is used in the treatment of malaria and rheumatological diseases in pregnant women. No significant adverse effects have been reported in these uses (9,10). It is known that the combination of lopinavir / ritonavir does not increase the frequency of fetal anomaly in pregnancy during antiviral use (11).
There is no information to show that pregnant women are more sensitive to COVID-19. There is no evidence that it can cause intrauterine infection and cause congenital infection. However, as the number of cases is low, it is difficult to make a firm decision on this issue (6,12). In a case series of 9 pregnant women with COVID-19, clinical findings were similar to those who were not pregnant. Fever in seven of the cases, cough in four, muscle pain in three, sore throat and weakness in two were reported. In five cases, white blood cell counts were observed, and in three cases aminotransferase elevation was observed. In all cases, there was no need for mechanical ventilation while developing pneumonia (13).
In another case series, six of 9 pregnant women developed stress in the fetus, while six were born prematurely (14). While maternal death did not occur in either series, no virus was found in infants. It is believed that there is no transition of the disease from mother to baby (7). However, since the number of cases is low, it is difficult to be sure about this issue. To date, 7 (22%) cases of 32 pregnant women (including those mentioned) diagnosed with COVID-19 have progressed without any findings. Two cases (6%) received intensive care support, while one showed severe respiratory failure. There are no maternal deaths reported so far. Twenty-seven of the cases were delivered by caesarean section and two by vaginal delivery. While preterm delivery occurred in 15 cases (47%), intrauterine infant death occurred in one case and newborn death occurred in one case. There was no transition from mother to baby in 25 cases that were investigated (15).
In the last 20 years, two separate coronaviruses have caused severe illness in humans: “Severe acute respiratory syndrome coronavirus (SARS-CoV)” and “Middle East respiratory syndrome coronavirus (MERS-CoV)”. SARS appeared in February 2003 and 8000 infected The mortality rate in pregnant women was reported as 25% (17), whereas MERS occurred in 2013, 860 deaths in 2500 cases, and the mortality rate in pregnant women was reported as 23% (7). -2 is 79% similar to SARS-CoV and 50% similar to MERS-CoV as a genetic structure (18).
COVID-19 and Management in Pregnancy
Management of COVID-19 during pregnancy, early patient isolation, rapid infection control measures, SARS-CoV-2 and additional infection tests, oxygen therapy, avoiding excess fluid loading, antibiotics if necessary, monitoring of baby and uterine contractions, mechanical ventilation in case of progressive respiratory failure requires individual birth timing and teamwork from various branches. The use of cortisone is sometimes not recommended in case of pneumonia. When cortisone is required to mature the lung in the baby, it is recommended to consult infectious diseases (7). Detailed information about the diagnosis and management of COVID-19 is issued by T.C. It can be accessed from the relevant page of the Ministry of Health (https://hsgm.saglik.gov.tr/tr/bulasici-hastaliklar/2019-n-cov.html).
Going Out of Home
Pregnant women should not visit or travel to risky places. In Chinese-based guidelines, it is reported that pregnant women should wear masks when visiting hospitals and high-risk places (19).
Suspicious Contact Cases
In case of suspicious contact of the pregnant woman, if no other reason is required to be hospitalized, she is asked to stay at home for 14 days and stay away from public areas as much as possible. In cases where it is necessary to go to public areas, it is requested to wear a medical mask. It is recommended not to accept visitors to the house, to ventilate the room well, to stay as separate as possible from other members of the household, to use different towels, different crockery and kitchenware and eat at different times (4,6). The examination can be postponed except for emergencies until the required isolation time (14 days) expires after a suspicious contact.
Suspected or diagnosed and mild cases should be followed up with ultrasonography every 2-4 weeks after recovery and amnion, if necessary with Doppler (20).
Insulation and Follow-Up in Hospital
- A pregnant woman with a diagnosis or suspicion of COVID-19 should be followed up by a gynecologist and obstetrician, in cooperation with a multidisciplinary team, including perinatology, infectious diseases, chest diseases, anesthesia and neonatal specialists.
- Suspected / diagnosed cases should be followed in isolation with negative pressure chambers. If this is not possible, there should be at least 1 meter distance with other patients (4).
- Oxygen saturation in the blood should be monitored and arterial blood gas, whole blood, kidney and liver function tests and coagulation tests should be requested. Cultures should be taken for secondary bacterial infections (20).
- In cases with moderate / severe findings diagnosed with COVID-19, imaging of the lung can be done by direct radiography and CT, while preserving the fetus (6).
- Treatment for findings is recommended in mild cases, 26-28. Fetal heartbeat and uterine contraction should be followed from weeks, fetal growth and amniotic fluid should be monitored on ultrasonography and Doppler should be used if necessary (20).
- In severe cases, pneumonia treatment includes antibacterial therapy, blood pressure, fluid-electrolyte balance control and maintenance, oxygen therapy, and fetal and uterine contraction monitoring, if necessary. The decision of preterm delivery should be made by the multidisciplinary team according to the benefit-loss balance. In the event that the microbe gets into the blood (sepsis), the specific management method for pregnant women should be prioritized (6,20).
- The harm of using cortisone for lung maturation in the baby has not been shown. However, it has not been shown that these drugs are useful in the treatment of coronavirus (6).
Management at Birth
COVID 19 (+) cases, starting labor, T.C. In conditions reported by the Ministry of Health, it should be followed up in the maternity unit in isolated rooms with negative pressure (4). Issues to be considered in follow-up are (6):
- Maternal fever, oxygen saturation in the blood, respiratory rate, pulse and blood pressure should be closely monitored.
- Fetus should be followed up with Continuous Electronic Fetal Monitoring.
- Blood Oxygen saturation should be kept tutul 95%.
- There is no clear suggestion regarding the mode of delivery. In the series, deliveries were mostly performed by cesarean section (13,14). Respiratory distress in pregnant women is thought to play a role in higher cesarean rates. There is no evidence that vaginal secretion creates a risk of transition to the baby.
- All babies born from COVID 19 (+) mothers should be tested for COVID-19.
- Some papers published in China suggested that those with COVID-19 (+) should be separated from their babies for 14 days. However, this may have negative effects on mother bonding and nutrition. In this respect, it is recommended to keep the mother and baby together. This situation should be decided by the multidisciplinary team according to the benefit-loss balance (6).
There is currently no evidence that the virus can be carried in breast milk. Therefore, the well-known benefits of breastfeeding are thought to outweigh the potential risk of transmission. Risks of close contact of mother and baby should be decided by the multidisciplinary team according to the benefit-harm balance. In breastfeeding, the following measures are recommended (6):
- Before touching the baby, baby bottles or milking pumps, you should definitely wash your hands.
- When feeding the baby on the breast, a face mask should be worn.
- Suggestions for cleaning pumps should be followed after each use.
- An experienced person should be asked for help in giving milk to the baby.
- Strict sterilization rules should be followed, and a special pump should be used for each mother.
- Turkish Maternal Fetal Medicine and Perinatology Association. http://www.tmftp.org/files/Duyurular/corona2.pdf
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