Pregnant women as well as the care givers require special attention in relation to prevention, diagnosis and management. Based on the limited information available as yet and our knowledge of other similar viral pulmonary infections, Available guidelines are refereed to.

1. Dr. Sujnanendra Mishra
PREGNANCY,
CHILDBIRTH CARE
AND COVID-19

2. Coronavirus Disease 2019 (COVID-19) is an emerging disease.
More lethal than previous viral Respiratory Syndrome
Since its first identification in Wuhan China, in December 2019 , Millions of
infections and nearly a million deaths have been registered GLOBALLY.
As limited data are available about COVID-19 during pregnancy. Information
on illnesses associated with other highly pathogenic coronaviruses {i.e.,
severe acute respiratory syndrome (SARS) and the Middle East respiratory
syndrome (MERS)} has also been examined.
The latest data on COVID-19’s effects during pregnancy has also been
incorporated.
NOVEL AND, LITTLE IS KNOWN

3. ABOUT
CORONAVIRUS

4. The oldest common ancestor of coronavirus has been dated as
far back as the 9th century BC. Some studies published in 1990
specified the most recent common ancestors as follows:
● Betacoronavirus: 3300 BC
● Deltacoronavirus: 3000 BC
● Gammacoronavirus: 2800 BC
● Alphacoronavirus: 2400 BC
HISTORY

5. HISTORY
Outbreaks
of Recent
coronavirus
diseases
MERS-CoV SARS-CoV SARS-CoV-2
Disease MERS SARS COVID-19
Outbreaks
2012, 2015,
2018
2002–2004
2019–2020
pandemic
Epidemiology
Date of first
identified case
June
2012
November
2002
December
2019
Location of first
identified case
Jeddah,
Saudi Arabia
Shunde,
China
Wuhan,
China
Age average 56 44 56
Sex ratio 3.3:1 0.8:1 1.6:1
Confirmed cases 2494 8096 1,446,242
Deaths 858 774 83,424
Case fatality rate 37% 9.2% 5.8%

6. Model of an infected alveolus in the lung. Type I and type II pneumocytes make up the alveolar walls and
resident alveolar macrophages and pulmonary surfactant exist in the airspace (A). In the acute phase of
SARS‐CoV infection (B), type I and type II pneumocytes are infected and secrete inflammatory cytokines, while
surfactant levels decrease. During the late stage/tissue damage portion of viral infection, viral titres decrease,
while airway debris, pulmonary oedema and hyaline membrane formation all impede respiration (C).
Molecular pathology of emerging coronavirus
infections
The Journal of Pathology, Volume: 235, Issue: 2, Pages: 185-195, First published: 01 October 2014, DOI: (10.1002/path.4454)

7. Airborne transmission is different from droplet
transmission as it refers to the presence of
microbes within droplet nuclei, which are
generally considered to be particles <5μm
in diameter, can remain in the air for long
periods of time and be transmitted to
others over distances greater than 1 m.
Transmission may also occur through fomites in
the immediate environment around the
infected person. by direct contact with
infected people and indirect contact with
surfaces in the immediate environment or
with objects used on the infected person
(even stethoscope or thermometer).
Respiratory Droplets Direct Contact
HOW IT SPREADS

9. 1. SUSPECTED:
2. PROBABLE
3. CONFIRMED
DIAGNOSIS OF INFECTION AND
CLINICAL CLASSIFICATION of CASES

10. 1. A patient with acute respiratory illness AND
2. No other etiology that fully explains the clinical presentation AND
3. history of travel to or residence in a place, reporting local transmission of COVID‐19
infection during the 14 days prior to symptom onset;
SUSPECTED
1. A patient with any acute respiratory illness AND
2. Has been in contact with a confirmed or probable case of COVID‐19 infection in the
14 days prior to onset of symptoms;
1. A patient with severe acute respiratory infection (fever and at least one
sign/symptom of respiratory disease (e.g. cough, shortness breath) AND
2. Requires hospitalization AND
3. Has no other etiology that fully explains the clinical presentation.
OR
OR

11. 1. A suspected case for which laboratory testing for COVID‐19 is inconclusive.
2. A contact, defined as a person involved in any of the following:
a. Providing direct care for COVID‐19 patients without using proper personal protective
equipment (PPE).
b. Being in the same close environment as a COVID‐19 patient (including sharing
workplace, classroom or household, or attending the same gathering)
c. Traveling in close proximity (within 1–2 meters) to a COVID‐19 patient in any kind of
conveyance
PROBABLE

12. 1. A person with laboratory confirmation of COVID‐19 infection,
irrespective of clinical signs and symptoms. CAN BE
a. Symptomatic
b. Asymptomatic
CONFIRMED

13. Specimen collection and storage
(adapted from https://www.who.int/ihr/publications/WHO_CDS_CSR_EDC_2000_4/en/)

14. 1. RAPID ANTIBODY TEST
2. CONFIRMATORY TESTS
DIAGNOSIS
One or more negative results do not rule out the possibility of COVID-19 virus infection.
A number of factors could lead to a negative result in an infected individual.
WHO/COVID-19/laboratory/2020.5

15. PREVENTION IN HEALTH CARE
01. Droplet precautions: 02. Contact precautions:
Put a mask on the patient; single room;
healthcare worker uses PPE
appropriately, including a mask, upon
entry to room.
Single room; healthcare worker uses PPE
appropriately upon entry to room,
including gloves and gown; use
disposable equipment
03. Airborne precautions:
Put a mask on the patient; negative‐pressure isolation room; healthcare
worker uses PPE appropriately upon entry to room, including wearing a
fit‐test approved respirator, gloves, gowns, face and eye protection;
Negative‐pressure isolation room; restrict susceptible healthcare workers
from entering the room; use disposable equipment

16. PREGNANCY AND
CHILDBIRTH CARE

17. 1. ANTENATAL CARE
2. CARE DURING CHILDBIRTH
a. PLACE OF CARE
b. TRANSPORT
c. HEALTH PERSONNEL
d. SPECIAL CARE
e. OBSTETRIC CARE
3. POSTPARTUM CARE
4. CARE OF THE BABY
TREATMENT DURING PREGNANCY

18. 1. Reduce RISK of exposure of the Healthy pregnant women to
Asymptomatic carrier and PUI.
2. Reduce health care workers’ exposure to prenatal patients that
may be COVID19+ but are asymptomatic.
3. Appropriate clinic spacing and social distancing may not be
possible.
4. Possibility of closure of few services due to Reduced Human
resource in the clinic
ANTENATAL CARE
Reduce antenatal visits
All laboratory tests and ultrasound tests that are time sensitive should still be completed
(i.e., 20-week US scan, dating US scan, diabetes screen, genetic screening, 35-37 week GBS screen)

19. • First Trimester
• Contact 1: up to 12 weeks – recommended in-person visit for this or next visit.
• Second trimester
• Contact 2: 20 weeks – recommend in-person visit for this visit if not done in 1st
trimester
• Contact 3: 26 weeks – virtual visit recommended
• Third trimester
• Contact 4: 30 weeks – virtual or in-person
• Contact 5: 34 weeks – in-person if 30-week visit virtual
• Contact 6: 36 weeks – in-person
• Contact 7: 38 weeks – in-person
• Contact 8: 40 weeks – in-person
• Return for monitoring or discussion reg: induction at 41 weeks if not given birth.
ANTENATAL CARE
A. Low-risk healthy pregnant needs 8 contacts (virtual or in-person) in pregnancy with a healthcare provider.
VirtualCare

20. ANTENATAL CARE
B. Suspected and probable cases of COVID‐19 infection
• PLACE:
• Designated tertiary hospitals with effective isolation facilities and
protection equipment.
• Pregnant women with a mild clinical presentation may not initially
require hospital admission and home confinement can be
considered
• Transfer:
• Medical team should don PPE and keep themselves and their
patient a minimum distance of 1–2 meters from any individuals
without PPE.

21. ANTENATAL CARE
Suspected and probable cases of COVID‐19 infection
• General treatment:
• Maintain fluid and electrolyte balance;
• Symptomatic treatment, such as antipyretic, antidiarrheal medicines.
• Surveillance:
• Close and vigilant monitoring of vital signs and oxygen saturation
• conduct arterial blood‐gas analysis;
• Chest imaging (when indicated);
• Regular evaluation of CBC, RFT, LFT and Coagulation tests.
• Fetal monitoring: USG, CTG etc.
• Obstetric management according to the clinical and ultrasound findings.

22. CONFIRMED CASES
Suspected and probable cases of COVID‐19 infection
• Non‐severe disease:
• Blood‐pressure monitoring and fluid‐balance management;
• Symptomatic treatment, such as antipyretic, antidiarrheal medicines.
• Currently there is no proven antiviral treatment for COVID‐19 patients,
protocol of GOI to be followed. (patients should be counseled thoroughly on the potential adverse
effects of antiviral treatment for the patient herself as well as on the risk of Fetal Growth Retardation)
• Surveillance:
• Close and vigilant monitoring of vital signs and SpO2, ABG, Chest X Ray, CBC, RFT,
LFT, Coag Study.
• Fetal monitoring: USG, CTG etc.
• Obstetric management according to the clinical and ultrasound findings.

23. Care for pregnant at risk including obstetrical risks, fetal
risks, medical co-morbidities or psychosocial issues:
• Create an individualized care plan to determine the schedule of visits.
Not all contacts have to be in-person and virtual care can be
considered.
• Ensuring appropriate blood pressure screening (either home
monitoring or in-person visits) can be individualized.

24. 1. The degree of severity of COVID‐19 pneumonia to be assessed by Community-Acquired Pneumonia Severity
Index (PSI) for Adults
2. Severe pneumonia is associated with a high maternal and perinatal mortality rate, therefore, aggressive
treatment is required,
a. Oxygen therapy and chest physiotherapy.
b. The case should be managed in a negative‐pressure isolation room in the ICU, preferably
with the woman in a left lateral position, with the support of a multidisciplinary team
3. Appropriate antibiotic in combination with antiviral following discussion with microbiologists.
4. Blood‐pressure monitoring and fluid‐balance management: to maintain an average arterial pressure ≥ 60 mmHg
(1 mmHg = 0.133 kPa) and a lactate level < 2 mmol/L39.
5. Oxygen therapy: supplemental oxygen should be used to maintain oxygen saturation ≥ 95%40, 41; oxygen
should be given promptly to patients with hypoxemia and/or shock42, and method of ventilation should be
according to the patient's condition and following guidance from the intensivists and obstetric anesthetists.
6. Fetal monitoring: if appropriate, CTG for FHR monitoring should be undertaken when pregnancy is ≥ 26
28 weeks of gestation, and ultrasound assessment of fetal growth and amniotic fluid volume with umbilical artery
Doppler should be performed.
7. Medically indicated preterm delivery should be considered by the multidisciplinary team on a case‐by‐case
basis.
Severe and critical disease

25. 1. COVID‐19 infection itself is not an indication for delivery, unless there is a need to improve maternal
oxygenation.
2. Delivery should be conducted in a negative‐pressure isolation room.
3. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the
patient, gestational age and fetal condition, in China in almost all cases Cesarean Sections were done.
4. Chest imaging, especially CT scan, should be included in the work‐up of pregnant women with
suspected, probable or confirmed COVID‐19 infection.
5. spontaneous onset of labor with optimal progress, she can be allowed to deliver vaginally. Shortening the second
stage by operative vaginal delivery can be considered, as active pushing while wearing a surgical mask may be
difficult
6. In case os preterm labour in COVID 19 suspects or confirmed cases, ANCS should be given with risks must be
individualized. Tocolytics must not be given.
7. Dead embryos/fetuses and placentae must not be handed over to family, disposed appropriately.
8. Early Cord clamping is advocated.
9. Baby to be kept at least 2 meters away with a physical barrier.
10. If Breastmilk is considered careful milk expression must be ensured.
11. Psychiatric support must be ensured for the Mother.
12. No evidence of vertical transmission yet, But Basby may be tested for Covid 19 at an appropriate time.
MANAGEMENT DURING CHILDBIRTH
Attending the delivery without PPE is not acceptable even in suspects and PUI

26. 1. Maintain good personal hygiene.
2. Providing educational information (brochures, posters) in waiting areas.
3. Set up triage plans for screening.
4. staff should have appropriate protective equipment and be strictly compliant with hand hygiene.
5. Reduce the number of visitors.
6. Medical staff who have been exposed unexpectedly, while without PPE, to a COVID‐19‐infected pregnant
patient, should be quarantined or self‐isolate for 14 days.
7. Pregnant healthcare professionals should follow risk‐assessment and infection‐control guidelines
following exposure to patients with suspected, probable or confirmed COVID‐19
8. Healthcare professionals engaged in obstetric care and those who perform obstetric ultrasound
examinations should be trained and fitted appropriately for respirators and/or PAPR.
9. Following an ultrasound scan of a suspected, probable or confirmed COVID‐19‐infected pregnant patient,
surfaces of transducers should be cleaned and disinfected with disinfection agents with recommended
‘wet time’ for wiping transducers and other surfaces.
HEALTHCARE PROVIDERS

28. “Sexual and reproductive health
services are always vulnerable to
falling to the bottom of the priority list
because Decision-makers (male, white,
heterosexual, older, affluent) are not
the people who will suffer from lack of
access,”
—Françoise Girard, president of the International
Women’s Health Coalition

29. THANK YOU !
drsujnanendra@gmail. com