Optimizing anc in pregnant women in sars co v-2 times

OPTIMIZING ANC IN
PREGNANT WOMEN IN
SARS-CoV-2 TIMES
BROUGHT TO YOU BY
PHARMED LIMITED
1
Prof. Dr. Narendra Malhotra, MD, FICOG, FICMCH, FRCOG,
FICS, FMAS, AFIAP
Prof. Dubrovnik International University
Vice President, WAPM
Past President ISPAT (2017-2019); Past President ISAR ( 2016 – 2017)
Vice President SAFOG (2019-2021); Member FIGO guidelines committee
President FOGSI (2008-2009)

PROF. NARENDRA MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S., F.M.A.S., A.F.I.A.P.
• Prof.Sarajevo School of Science and Technology
• V.P. WAPM(world association of prenatal medicine)
• Past President ISPAT (2017-2019)
• Past President ISAR ( 2016 – 2017)
• Vice President SAFOG (2019-2021)
• Member FIGO guidelines committee
• President FOGSI (2008-2009)
• Dean I.C.M.U. (2008)
• Director Ian Donald School of Ultrasound. (India)
• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
• Managing Director GLOBAL RAINBOW HEALTH CARE, Agra
• Director ART-RAINBOW –IVF (Agra & Delhi)
• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy, ART & Genetics
• Member and Fellow of many Indian and international organizations
• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award, Corion award, Man of the year award,
Best Citizens of India award
• Over 65 published and 300 presented papers
• Over 300 guest lectures given in India & Abroad and 26 ORATIONS
• Organized many workshops, training programmes, travel seminars and conferences in India & in Asia
• Editor 25 books, many chapters, on editorial board of many journals,
• Editor Jeffcoate & Donald Obstetric Manual
• Chairman SMRITI (NGO) New Level of Care.
MALHOTRA NURSING & MATERNITY HOME PVT. LTD.
GLOBAL RAINBOW HEALTH CARE, AGRA
2

The virus and
modes of
transmission
Effect of SARS-
CoV-2 infection
on mother
Antenatal care
of non- SARS-
CoV-2 pregnant
women
Effect of SARS-
CoV-2 infection
on Fetus
OUTLINE
Antenatal
care for
suspected
or
confirmed
SARS-CoV-2
infection
3

Sneezing
Spread from
Person to
Person by
Cough
Touching mouth,
nose, eyes
before washing
hands
Currently
unknown if the
virus can
spread
through semen
or sexual
intercourse
Emerged
from Animal
Source
SARS-CoV-2 INFECTION
4

a.
Physiologic
changes in
pregnancy
Maternal disease
Not aggravated by
pregnancy unless
associated
comorbidities
Relative
immunosuppressi
on in pregnancy
b.
Both a & b to be
considered seriously
and associated
comorbidities to be
reviewed carefully
Pregnant women NOT
MORE susceptible to
Covid-19 vs. general
population
Some viral
infections are
serious in
pregnancy
IMPACT OF SARS-CoV-2 ON THE MOTHER
5

ASSESSMENT OF COMORBIDITIES : I
1. Hypertension
2. Diabetes
3. Asthma
4. HIV
5. Heart Disease
6

4
1
5
3
2
Blood Dyscrasia
Chronic Kidney Disease
Chronic Liver Disease
ASSESSMENT OF COMORBIDITIES : II
Chronic Lung Disease
Patients on
Immunosuppressive
Drugs
7

Important to take
precautions
against SARS-
CoV-2
To Report possible
symptoms to HCP
at the earliest
PRECAUTIONS & ACTIONS
8

Majority
Mild to Moderate
Cold/Flu
Cough Sore
Throat
Fever > 37.8 °C
CLINICAL PICTURE OF SARS-CoV-2 IN PREGNANCY
A few
SEVERE
Shortness of
breath→ Severe
Acute
Respiratory
Illness (SARI)
Pneumonia
Marked Hypoxia
Critically Ill
Tachypnoea
(>30/min)
Hypoxia: (SpO2
<93%)
Imaging: >50%
Lung involvement
Immunocompromised
& Elderly pregnant
women HIGH RISK.
Look for
fatigue, malaise,
body ache and/or
nausea &
diarrhoea
High-risk patients are to be classified on priority
9

NO REPORTED INCREASE OF
MISCARRIAGE /EARLY
PREGNANCY LOSS
PRE-TERM BIRTH REPORTED
(INADEQUATE NUMBERS)
UNCLEAR
IATROGENIC/SPONTANEOUS
EFFECT OF SARS-CoV-2 ON FETUS
NO EFFECT ON FETAL GROWTH
NO EVIDENCE OF
(1)INTRAUTERINE FETAL
INFECTIONS
(2) CONGENITAL
MALFORMATIONS
NO EVIDENCE OF
(1)VERTICAL
TRANSMISSION
(2) TRANSMISSION
THROUGH GENITAL FLUIDS
10

Consequences
of infection to
mother
Consequences
of infection to
Newborn
Spread of
infection from
pregnant
woman to HCP
Spread of
infection from
one pregnant
woman to
another
PREPAREDNESS IS THE ESSENCE
PREVENT
High-quality care before during and after childbirth (antenatal, intranatal & postnatal)
and mental health
11

Appropriate isolation of pregnant patients who have
confirmed SARS-CoV-2 or are Persons Under
Investigations
Basic and refresher training for all healthcare
personnel to include correct adherence to infection
control practices, Personal Protective Equipment
(PPE) use and handling (preferably by a video
presentation)
Sufficient and appropriate PPE supplies positioned
at all points of care
Processes to protect new-borns from risk of SARS-
CoV-2
OBSTETRIC UNIT PREPAREDNESS: ICMR
https://icmr.nic.in/sites/default/files/upload_documents/Guidance_for_Management_of_Preg
nant_Women_in_COVID19_Pandemic_12042020.pdf
12

Antenatal
contact
Diet
Hygiene
Attention to
infection prevention
and shielding
Travel &
Quarantine
1
3
2
4
ANTENATAL CARE FOR NON- SARS-CoV-2 PREGNANT WOMEN
Stringent preventive healthcare measures & Advice
Important Aspects
13

Social Distancing
ANTENATAL CLINIC FOR PREGNANT WOMEN IN SARS-CoV-2 TIMES
14

1 2 3
INFORMATIVE COUNSELING IN ANTENATAL CLINIC FOR PREGNANT
WOMEN IN SARS-CoV-2 TIMES
If you are
infected with
SARS-CoV-2
you are still
most likely
to have no
symptoms or
a mild illness
from which
you will
make a full
recovery.
If you develop more
severe symptoms or
your recovery is
delayed, this may be
a sign that you are
developing a more
significant chest
infection that
requires enhanced
care; you should
contact your
maternity care team
immediately.
There may be a
need to reduce
the number of
antenatal visits
you have.
However, do not
reduce your
number of visits
without agreeing
first with your
maternity team.
https://icmr.nic.in/sites/default/files/upload_documents/Guidance_for_Management_of_Preg
nant_Women_in_COVID19_Pandemic_12042020.pdf
15

01 Antenatal Visits/Routine Scan
Reduce/Postpone and Increase
intervals between visits
02 Duration of Visit
Shorten duration of antenatal
visits
03 Visitors
Absolute Limitation of
visitors in hospital
04 High-risk
cases
Prenatal/antenatal
surveillance
05 Plan of
Visits
ANTENATAL CONTACT
Individualize
frequent visits
Do the Basic Minimum 4:
Minimum contact at 12,
20, 28 & 36 Weeks
Antenatal Contact at longer intervals Except in high-risk cases
Less-frequent Routine Antenatal
Care in non-high risk pregnancies,
where surveillance is mandatory.
16

Teleconferencing
Videoconferencing
Either a Replacement
Or in Addition
Especially If maternal
Observation or Tests are NOT
needed
Virtual Prenatal Care Visits
(1) Online communication with
providers
(2) Consultation with
specialists, such as,
• Maternal/Fetal Medicine,
• Genetic Counselling
• Mental Health Care :
Severely Stressful
Condition
ANTENATAL TELEMEDICINE
17

Daily Foetal
Movement Count
Weight
HOME MONITORING
Wherever Possible
In All Cases
Blood Pressure
18

01 02
04 03
Vitamins/Micronutrient
SupplementationHigh-protein Diet
Consumption of
meat, chicken, eggs
-NO Increased Risk
of acquiring Corona
Virus
No particular diet to
improve immune
status or reduce
infection risk
DIETARY ADVICE
19

Hand
Hygiene:
Wash hands
frequently
Staying at
Home
Avoid
touching
face
Use masks -
Prevents
infection
Social
Distancing
Respiratory
Hygiene:
Coughing or
sneezing to a
bent elbow or
tissue
ADVICE ON HYGIENE
If any fever,
cough or
difficulty
breathing
Seek care early
Follow medical
advice
Attention to Infection
Prevention
5Do the
20

Avoid nonessential
travel
Avoid all
Nonessential
Overseas Travel
02
01
ADVICE ON TRAVEL & QUARANTINE
Criteria for
Quarantine
Same for pregnant
women and
general population
21

SHIELDING
Measures to protect clinically
extremely vulnerable people
Pregnant women
with significant
heart disease,
congenital or
acquired
Immunocompromised
women
19

Stay at home at all
times for at least
12 weeks
Access Medical
assistance remotely
wherever possible
Within Home, minimize all
nonessential contacts with
other home members
Family members should remain
in home and not bring in
infections from outside
0
1
0
2
0
3
0
4
.
SHIELDING
23
Minimize all interactions between extremely vulnerable group and others
Deploy
Shielding
Techniques &
Advice

Any gestation:
offer choice
whether to work
in direct patient-
facing role
Those who can
work from home
should be
allowed
ANTENATAL ADVICE FOR PREGNANT HEALTHCARE
WORKERS : PRIORITY
Less than 28
Weeks:
Practice Social
Distancing
May choose
patient-facing
roles with
precautions
24

1
2
3
>28 WEEKS/HCW WITH UNDERLYING
HEALTH CONDITIONS
AVOID DIRECT PATIENT CONTACT
RECOMMENDED: WORK FROM HOME
1
2
3
ANTENATAL ADVICE FOR PREGNANT HEALTHCARE
WORKERS : PRIORITY
Work from Home & Avoid Direct Patient Contact
25

Antenatal
contact
Isolation
Follow algorithm of
management
ANTENATAL CARE FOR PREGNANT WOMEN
With , Probable or Confirmed SARS-CoV-2 Infection
26

Suspected with
SARS-CoV-2
1
Asymptomatic
2
Symptomatic
Confirmed
SARS-CoV-2
+ve
Access to
Women-
centric
respectful
skilled care
(1)Obstetric care (2) Fetal medicine (3)
Neonatal care (4) Mental Health Care
(5) Psychosocial Support
with READINESS TO CARE FOR
MATERNAL & NEONATAL
COMPLICATIONS
With , Probable or Confirmed SARS-CoV-2 Infection
27

ACCESS TO
SKILLED CARE
Obstetric care
.
WITH SUSPECTED, PROBABLE OR CONFIRMED SARS-CoV-2 INFECTION
Must have access to women-centric respectful skilled care including
Foetal Medicine
.
Neonatal care Mental Health care
READINESS TO CARE FOR
MATERNAL & NEONATAL
COMPLICATIONS
PSYCHOSOCIAL SUPPORT
28

POWERPOINT TEMPLATE | Email : support@slidemodel.com | Web : slidemodel.com
ALGORITHM: MANAGEMENT OF ANTENATAL CARE
Step 01
Step 02
Step 03
Step 04
Step 05
WITH SUSPECTED, PROBABLE OR
CONFIRMED SARS-CoV-2 INFECTION

Symptoms
(1) No need to
(2) Contact
Maternity Team
Severe Symptoms or
Urgent Problems Related
to Pregnancy
Contact immediately
ANTENATAL CARE: SUSPECTED SARS-CoV-2 INFECTION
25
When to Contact?
Information to be passed to EVERY pregnant women
TIME TO CONTACT when suspected: Information sharing by HCP

PREGNANCY WITH SUSPECTED SARS-CoV-2 INFECTION
1
2
3
4
5
Use Private Transport
How to Contact?
26
Avoid Routine Clinic; Attend
Designated Area for Suspect Cases

ALGORITHM: ANTENATAL MANAGEMENT OF PREGNANT WOMEN
First point of
Contact/Initial
Assessment Area for
Triage and Screening
 Fever ≥38°C (100.4°F)
 Cough
 Difficulty breathing or Shortness of breath
 Gastrointestinal Symptoms
Patients with
32

First point of
Contact/Initial
Assessment Area for
 Fever ≥38°C (100.4°F)
 Cough
 Difficulty breathing or
 Shortness of breath
Patients with
OR (A) History of travel
to an affected country
within previous 14 days
33

First point of
Contact/Initial
Assessment Area for
 Fever ≥38°C (100.4°F)
 Cough
Patients with
 <1 meter for >15
minutes,
 living together, or
 direct contact with body
fluids
OR (B) Close contact with a
confirmed case of COVID-19
34

First point of
Contact/Initial
Assessment Area for
 Fever ≥38°C (100.4°F)
 Cough
Patients with
 <1 meter for >15 minutes,
 living together, or
 direct contact with body
fluids
OR (B) Close contact with
a confirmed case of COVID-
19
• Give the woman a
surgical face mask
• Maintain
minimum 1 m
distance from the
patient
35

Elevated Risk
Moderate Risk
ASSESSMENT OF SUSPECTED CASES
Infectious
Disease
Specialist
Severity
Assessment
Obstetrician
Assessment
Obstetric Emergency
Labor/Delivery Issue
36

Elevated Risk
Moderate Risk
Infectious
Disease
Specialist
Severity
Assessment
Obstetrician
Assessment
Obstetric Emergency
Admission
Manage
as per
guidelines
after
admission
Yes to Any or Both
37

Elevated Risk
Moderate Risk
Infectious
Disease
Specialist
Severity
Assessment
Obstetrician
Assessment
Obstetric Emergency
Isolation at home
for 14 days
No to Both
Clinical Self-
Monitoring
Persistence of
Symptoms:
Test for SARS-
CoV-2
(as per
guidelines)

MANAGEMENT OF SUSPECTED CASES NOT IN LABOR: I
Multidisciplinary Approach at All
Times
Transfer IMMEDIATELY to an
identified Isolation Room
HCP must don an appropriate PPE
TEST pregnant woman with
Suspected Infection on Priority & Urgently
01
04
03
02
Institute Infection Prevention & Control (IPC) measures
Obstetric
Neonatal
Intensive
care
Specialists

Send
samples of
Nasopharyn
geal Swab
1
Do NOT
Delay
Obstetric
Care in
order to Test
2
Until Test Results are
available, treat her as
confirmed SARS-CoV-2
3
slidemodel.com
MANAGEMENT OF SUSPECTED CASES NOT IN LABOR: II
To be collected as per guidelines by appropriate
personnel
To be transported in the
right way

RECHECK
AFTER 2 WEEKS
HOME ISOLATION
FOETAL DOPPLER &
FOETAL GROWTH
MANAGEMENT OF CONFIRMED CASES: ASYMPTOMATIC
(ANTENATAL SARS-CoV-2 POSITIVE) PREGNANT WOMEN
1. Asymptomatic
2. No comorbidities
3. No Obstetric
Emergencies/Labor

ANTENATAL CONTACT: ASYMPTOMATIC SARS-CoV-2
POSITIVE PREGNANT WOMEN
33
Growth Scans,
OGTT, Regular AC
Appointments
Antenatal
Contact
Regular Antenatal Care

PATIENTS’ CONCERNS ABOUT WELLBEING OF SELF
OR FETUS DURING SELF-ISOLATION
05
04
03
02
01
Ensure she gets
Necessary Counselling
Provide information on potential
risks of adverse pregnancy
outcomes
Ensure she gets necessary
numbers and she knows how to
get there
Advise to contact Maternity
Team
34
Additional care
if any complications

MANAGEMENT OF CONFIRMED CASES
Hospitalize the pregnant women based on
36
SYMPTOMATIC (SARS-CoV-2 POSITIVE PREGNANT WOMEN)

04 Critically ill: Tachypnoea (>30/min) Hypoxia
(SpO2<93%) Imaging >50% Lung involvement
03 Immunocompromised & Elderly Pregnant
Women Fatigue Malaise Bodyache Nausea
Diarrhea
02
Certain Cases Severe with Shortness of breath:
SARI, Pneumonia, Marked Hypoxia
01 Majority Only Mild to Moderate Cold/Flu with (1) Cough (2) Sore Throat
& (3) Fever above 37.8°C
ASSESSMENT OF SEVERITY: SUSPECTED CASES IN LABOR
32
01MONITOR
MONITOR MATERNAL
EARLY WARNING SIGNS
OR SOFA

POWERPOINT TEMPLATE | Email : support@slidemodel.com | Web : slidemodel.com
ASSESS NEED FOR ICU ADMISSIONS BASED ON
1 2
Maternal Early
Warning Criteria
Sequential Organ
Failure
Assessment Tool

Oxygen saturation in Room Air
<94%
Oliguria defined as urinary
output <35 mL/Hour for ≥2
hours
Maternal confusion, agitation,
unresponsiveness
Known patient with
preeclampsia reporting a
nonremitting headache or
shortness of breath
Systolic BP <90 or >160 mmHg
Diastolic BP >100 mmHg
Heart Rate <50 or >120/min
Respiratory Rate <10 or
>30/min
01
02
03
04
05
06
07
08
37
MATERNAL EARLY WARNING CRITERIA
CONFIRMED OR SUSPECTED CASES IN ANTENATAL CARE

Systolic BP <100
mmHg
Respiratory Rate
>22
Altered Level of
Consciousness
B
A
C
01
02
03 (2/ 3)
38
QUICK SEQUENTIAL ORGAN FAILURE ASSESSMENT TOOL
(SOFA)
CONFIRMED OR SUSPECTED CASES IN ANTENATAL CARE

AGENDA
TOPIC 1
TOPIC 2
CLOSING
Maternal Early
Warning
Criteria/SOFA
X
Continue
Monitoring

Maternal Early
Warning
Criteria/SOFA
ICU Admission
Severe
Failure
Septic
Shock
Acute Organ
Failure
Consider Emergency Cesarean
Delivery



 49

01
Maternal
Surveillance
Temperature,
HR, BP, RR (3-4
times/day)
02
Chest
Imaging
High-Res CT
Scan or X-
Ray
03Consider O2
therapy to keep
O2 saturation
>95%
04
Encourage Oral
Hydration;
limit IV fluid if
concern for
cardiovascular
instability
MONITORING OF CONFIRMED CASES
(SARS-CoV-2 POSITIVE PREGNANT WOMEN)
Only if indicated
With abdominal shield
After informed consent
50

Infection Screening
Screen for other viral
infections and/or
superimposed bacterial
infections
.
Empiric Anti-infectives
Consider empiric IV/oral
antibiotics/Antimalarial
/Antiviral
Antipyretic
therapy
• Maternal comfort
• Limit foetal risk of
maternal
increased body
temperature
Consider
thromboprophylaxis
Thromboprophylaxis
4 1
23
DRUG THERAPY DURING ADMISSION
(SARS-CoV-2 POSITIVE PREGNANT WOMEN)
51

FOETAL SURVEILLANCE : SYMPTOMATIC CONFIRMED CASES
Foetal Heart
Rate Antenatal
Corticosteroids
Mild C SARS-CoV-2 Clinical
benefits may overweigh
the risks of potential
harm to mother
Daily Foetal Movement
Count
Women at risk of preterm
birth 24-34 Wks. with NO
INFECTION
52

Recovery from Illness
Post Recovery* from
Illness
Detailed mid-trimester
anatomy ultrasound
examination
*Little evidence of natural
history of pregnancy after
recovery
Recovery from infection in the
latter half of pregnancy
Sonographic assessment of
fetal growth 2 weeks after
recovery
POST RECOVERY ANTENATAL CARE FOR PREGNANT
WOMEN WITH CONFIRMED SARS-CoV-2 INFECTION
Antenatal Contact
Recovery from infection in
First Trimester
53

LATEST ICMR GUIDELINES April 2020
54
MANAGEMENT OF COVID-19 IN PREGNANCY
FLOWCHART FOR MANAGEMENT IN PREGNANT WOMEN ICMR
Pregnant Women with SARS-CoV-2 Exposure
Traveled to an affected country in the previous 14 days
Close contact with a confirmed case of COVID-19 (i.e., <1 metre for >15 minutes, living together, direct contact with
body fluids
Clinical Examination + RT-PCR (SARS-CoV-2) on Deep Nasopharyngeal & Pharyngeal Samples
ASYMPTOMATIC
No Isolation Rooms
SYMPTOMATIC
Fever >38°C AND Respiratory Symptoms
MONITORING AT HOME
(T° + Respiratory Symptoms)
MONITORING AT HOSPITAL
Isolated Room preferably with Negative Pressure (IRNP)
Protective gear for visitors & Health Personnel
Delivery & Neonatal Procedure equipment on site

55
MONITORING AT HOME MONITORING AT HOSPITAL
SARS-CoV-2
NEGATIVE
SARS-CoV-2 POSITIVE SARS-CoV-2 NEGATIVE SARS-CoV-2 POSITIVE
Stop
Monitoring
Isolation at Home X 14
Days
If Delivery
Breastfeeding as per
guidelines
Mother Isolated from
newborn until Viral
shedding clears
Isolation at Home
X 14 Days
Clinical Self-Monitoring
If Symptoms Persist
RETEST
(Possible False
Negative)
HOSPITALIZATION
IN TERTIARY
CENTRE
Maternal
Surveillance
T°, HR, BP, RR (3-4Xday)
Chest Imaging (HRCT/X-Ray)
Fetal:
-FHR (1X/Day)
-Fetal Maturation by
Betamethasone Injection
depending on maternal status
(until 34-37 weeks)
-IV Antibiotic Treatment Depending
on Local Protocol
USG Foetal Surveillance
Growth + Doppler /2
Weeks
RECOVERY

56
HOSPITALIZATION IN TERTIARY CENTRE
Maternal Surveillance T°, HR, BP, RR (3-4Xday) Chest Imaging (HRCT/X-Ray)
Fetal:
-FHR (1X/Day) -Fetal Maturation by Betamethasone Injection depending on
maternal status (until 34-37 weeks) -IV Antibiotic Treatment Depending on Local
Protocol
INTENSIVE CARE UNIT ADMISSION
(QUICK SOFA SCORE)
More Than 1 Following
Criteria
-Systolic BP <100 mmHg
-Respiratory Rate >22
-Glasgow Conscious Score <15
SEVERE FAILURE CRITERIA
Consider Cesarean Delivery
-SEPTIC SHOCK
-ACUTE ORGAN FAILURE
-FETAL DISTRESS
DELIVERY
Before 24 Wks.
-Severe maternal illness-Consider MTP if
Legal
After 24 Wks.
-On site/IRNP
-Vaginal Delivery (Induction of Labor
+Instrumental delivery when possible unless
severe failure criteria)
-Early cord clamping & cleaning of the new
born
-Newborn Monitoring in the IRNP
-SARS-CoV-2 RT-PCR of the newborn
-Breastfeeding with due precautions and
considerations
-Mother isolated from newborn until viral
shedding resolves
*PROTECTIVE GEAR
Contact & Airborne
Additional Measures
-FFP2 OR N95 Mask
-Gloves
-Gown
-Eye Protection

OUR GUIDELINES TESTING BEFORE
57

TAKE-HOME POINTS
Pregnant women should
follow same
recommendations as non
pregnant women for avoiding
exposure to SARS-CoV-2
pandemic
Antenatal care through
teleconferencing and
videoconferencing is the key
to provide quality care
during this pandemic
Triage based on symptom
severity and obstetric
emergencies and
Multidisciplinary approach
to management od suspected
or confirmed cases
42

REFERENCES
 Clinical management of severe acute respiratory infection when COVID-19 is suspected.
https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-
when-novel-coronavirus-(ncov)-infection-is-suspected WHO
 Coronavirus (COVID-19) infection and pregnancy. https://www.rcog.org.uk/coronavirus-pregnancy
.RCOG
 Coronavirus & Pregnancy. https://www.obgproject.com/2020/04/02/coronavirus-and-pregnancy-
early-data-on-risk-for-vertical-transmission-of-covid-19-infection-and-potential-risks-for-pregnant-
women/SMFM
 FOGSI’S GCPR on – Pregnancy with COVID – 19 infection. https://www.fogsi.org/the-draft-version-1-
fogsi_gcpr_on_pregnancy_with_covid_19_infection/FOGSI
 COVID-19 Statement . https://ranzcog.edu.au/statements-guidelines/covid-19-statementRANZCOG
 https://icmr.nic.in/sites/default/files/upload_documents/Guidance_for_Management_of_Pregnant_
Women_in_COVID19_Pandemic_12042020.pdf
43

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