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Covid19 & pregnancy

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Aboubakr Mohamed Elnashar

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Covid19 & pregnancy

  1. 1. 5/8/2020 ABOUBAKR ELNASHAR 1 COVID-19 & Pregnancy What obstetrician needs to know?  Sexual intercourse  Infertility  ART  Pregnancy Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR  Vertical transmission (transmission from mother to baby antenatally or intrapartum)  China: no evidence {amniotic fluid, cord blood, neonatal throat swabs, placenta swabs, genital fluid, breast milk samples from infected mothers: negative for the virus}.  RCOG, 2020, 21 April: probability  2 reports: {IgM for SARS-COV-2 in neonatal serum at birth. Since IgM does not cross the placenta,± represent a neonatal immune response to in utero infection}.ABOUBAKR ELNASHAR
  2. 2. 5/8/2020 ABOUBAKR ELNASHAR 2 Sexual transmission (UNICEF, 2020)  NO {not found in semen or vaginal fluid}  But: SI involves close contact, kissing& touching, these are the ways of transmitting this virus  Avoid sex if you or your husband (New York City Health, 2020) 1. Confirmed Covid19 2. Suspected Covid 19 3. High risk for severe Covid-19 ABOUBAKR ELNASHAR DIAGNOSIS  Suspected cases (22.4.2020) ABOUBAKR ELNASHAR
  3. 3. 5/8/2020 ABOUBAKR ELNASHAR 3 22.4.2020 ABOUBAKR ELNASHAR  Single chest radiograph  Very low fetal radiation dose (0.0005 to 0.01 mGy) Abdominal shielding  CT  should be performed, if indicated  fetal radiation dose is low  Not associated with an increased risk of  fetal anomalies or  pregnancy loss.  Pulmonary ultrasound  quick diagnosis of pneumonia ABOUBAKR ELNASHAR
  4. 4. 5/8/2020 ABOUBAKR ELNASHAR 4 ABOUBAKR ELNASHAR EFFECTS ON PREGNANCY 1. Maternal  Not more likely to contract COVID19 1. More severe infection  Pneumonia  Marked hypoxia  In late pregnancy, compared with early pregnancy.  The absolute risks: Small 2. Increased risk of DVT {Reduced mobility from self-isolation at home, or hospital admission} ABOUBAKR ELNASHAR
  5. 5. 5/8/2020 ABOUBAKR ELNASHAR 5 2. Effect on the fetus  No increased risk of  Miscarriage or early pregnancy loss  Teratogenicty . 1. Fetal compromise 2. Prelabour PROM 3. Hyperthermia during organogenesis: congenital anomalies, NTD, or miscarriage.(Theoretical) ABOUBAKR ELNASHAR  Yan et al, 2020. 24 April 116 pregnant women withCOVID-19 in China  The most common symptoms  Fever: 50.9%  Cough: 28.4%  No sym: 23.3%.  Abnormal radiologic findings in 96.3% of cases.  Severe pneumonia: 6.9%. no maternal deaths.  PTL: 23.2%  Spontaneous PROM: 6.1%  CS: 85.9%  NICU: 47% Neonatal death: 1%.ABOUBAKR ELNASHAR
  6. 6. 5/8/2020 ABOUBAKR ELNASHAR 6 MANAGEMENT  MULTIDISCIPLINARY TEAM 1. Chest specialist 2. Intensivist 3. OBSTETRICIAN 4. Anesthesiologist 5. Neonatologist 6. Microbiologist 7. infection control specialist A. MEDICAL B. OBSTETRICAL ABOUBAKR ELNASHAR A. MEDICAL 22.4.2020 ABOUBAKR ELNASHAR
  7. 7. 5/8/2020 ABOUBAKR ELNASHAR 7 ABOUBAKR ELNASHAR OBSTETRICAL I. ANTENATAL CARE (RCOG, 2020)  Appointments  Limited with remote consultation by telephone  Women who have had symptoms  deferred until 7 days after the start of symptoms, unless symptoms (aside from persistent cough) persevere.  Suspected or confirmed COVID-19  delayed until after the recommended period of isolation 14 days ABOUBAKR ELNASHAR
  8. 8. 5/8/2020 ABOUBAKR ELNASHAR 8  Antenatal Clinic  Separate for suspected or confirmed COVID-19.  Dedicated team  appropriate PPE.  Dedicated equipment  Remove non-essential items  US machine  decontaminated after each use.  Transducers are cleaned and disinfected  Protective covers for probes and cables. ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR
  9. 9. 5/8/2020 ABOUBAKR ELNASHAR 9  Procedures  US & other investigations (urine &blood tests in same visit  US for F growth& anatomy.  Electronic FHR monitoring  Doppler assessment  Amniocentesis  Not recommended in active infection. ABOUBAKR ELNASHAR 2. Use of medications to manage pregnancy  Antenatal betamethasone  CDC: avoiding glucocorticoids in COVID-19- positive { increased risk for mortality}  ACOG: between 24+0 &33+6 w in patients at high risk of PTL within 7 days  Not 34+0 to 36+6 w  {benefits to the neonate are less clear} ABOUBAKR ELNASHAR
  10. 10. 5/8/2020 ABOUBAKR ELNASHAR 10  Low-dose aspirin  For prevention of PET.  Suspected or confirmed COVID-19 for whom LDA would be indicated, the decision to continue should be individualized & is usually possible.  Continuing is not worthwhile in  Severely or critically ill patients or  Near term ABOUBAKR ELNASHAR  NSAIDs (ibuprofen)  Early in the course of infection: severe disease  No clinical or population-based data that directly address the risk of NSAIDs.  WHO do not recommend avoiding NSAIDs in COVID-19 patients when clinically indicated  Acetaminophen  In the first trimester  Fever ABOUBAKR ELNASHAR
  11. 11. 5/8/2020 ABOUBAKR ELNASHAR 11  Tocolysis  Nifedipine  Not:  Indomethacin, which is subject to the concerns discussed above  Beta sympathomimetics, which can further increase the maternal heart rate. ABOUBAKR ELNASHAR 3. Delivery timing  Depend upon: 1. Mother's clinical status 2. Gestational age 3. Fetal well-being.  Improvement mother's condition: improve fetal status: pregnancies allowed to continue to term.  If woman is critically ill, deterioration : IUF demise or loss of both mother& infant: early delivery  Infectious: Elective CS ± delayed, if possible ABOUBAKR ELNASHAR
  12. 12. 5/8/2020 ABOUBAKR ELNASHAR 12  Mg sulfate —  Indication  maternal seizure prophylaxis  neonatal neuroprotection  Women with respiratory compromise {Mg sulfate ±depress respirations}.  Consultation with maternal-fetal medicine& pulmonary/critical care specialists. ABOUBAKR ELNASHAR II.INTRAPARTUM 1. Evaluation of all patients on admission 2. PPE on labor  All clinicians  All asymptomatic patients 3. Mode of delivery  Based on obstetric indications, as there is no clear benefit of delivery via CS  Seriously ill patients & need urgent delivery should be by category 1 CS. ABOUBAKR ELNASHAR
  13. 13. 5/8/2020 ABOUBAKR ELNASHAR 13 4. Analgesia & anesthesia  Regional Anasthesia by epidural or spinal  Recommended .  General anesthesia (intubation & extubation)  Considered an aerosolizing procedure  The scrub team should  Scrub & wear PPE (N-95) before the general anesthesia is commenced. ABOUBAKR ELNASHAR  Nitrous oxide  Not recommended  {insufficient data about cleaning, filtering, potential aerosolization of nitrous oxide systems}.  Intravenous, patient-controlled analgesia  limiting use  {risk of respiratory depression}. ABOUBAKR ELNASHAR
  14. 14. 5/8/2020 ABOUBAKR ELNASHAR 14 5. Labor management  Person-to person contact & time in the labor unit & hospital should be limited  Maternal observations:  T, RR, oxygen saturation to be kept above 94%.  Fluid chart to avoid fluid overload.  Continuous CTG  Shortening of the second stage ABOUBAKR ELNASHAR  Rupture of membranes&internal FHR monitoring  ±performed, but data are limited  {COVID19 has not been detected in vaginal secretions or amniotic fluid}  Pushing  often causes loss of feces, which can contain the virus & spread the infection  Not delaying pushing in 2nd stage. ABOUBAKR ELNASHAR
  15. 15. 5/8/2020 ABOUBAKR ELNASHAR 15  Delayed cord-clamping:  Unlikely to increase the risk of transmitting virus from infected mother to the fetus (ACOG, RCOG, EMH, April 2020)  Oxygen therapy for fetal resuscitation  Should be abandoned {no proven fetal benefit nasal cannula& face mask used are in contact with the maternal respiratory tract& secretions: increases contamination/exposure between pt. &provider}. ABOUBAKR ELNASHAR  Neonate should be  Cleaned& dried immediately  Leaving vernix caseosa in place for 24 h since it contains antimicrobial peptides.  Isolated for 14 days  Closely monitored for clinical manifestations of infection.  The mother & newborn  May need to be isolated separately until both are cleared ABOUBAKR ELNASHAR
  16. 16. 5/8/2020 ABOUBAKR ELNASHAR 16 III. Post partum care 1. Placental disposal  The placenta should be treated as biohazardous waste ABOUBAKR ELNASHAR 3. Breast feeding: (EMH, April 2020)  Not recommended.  If the mother is severely or critically ill  express breast milk with a pump to maintain milk production (the pump should be cleaned after each use).  Can be considered  If the mother is asymptomatic or mildly affected, {virus is transmitted by respiratory droplets rather than breast milk}  Mothers should:  wash their hands  wear a mask  avoid coughing or sneezingABOUBAKR ELNASHAR
  17. 17. 5/8/2020 ABOUBAKR ELNASHAR 17 5. Postpartum fever  COVID-19 should be part of the dd particularly  respiratory symptoms &  reduced oxygenation.  Such patients should be  tested for the virus  evaluation for common causes of intrapartum &postpartum infection:  Chorioamnionitis  Endometritis ABOUBAKR ELNASHAR 6. Postpartum office visits  Should be limited to reduce the risk of inadvertent exposure.  Early postpartum assessments: wound &blood pressure checks, with telephone.  After 4-8 w: psychological assessment  Screen for postpartum depression: self-report, 10-item Edinburgh Postnatal Depression Scale, which can be completed in 5 minutes  Severe anxiety and support offered.  After 12W: A comprehensive assessment especially in patients with comorbiditiesABOUBAKR ELNASHAR
  18. 18. 5/8/2020 ABOUBAKR ELNASHAR 18 TAKE HOME MESSAGE 1. No evidence of miscarriage, F. congenial fetal malformation. 2. It may cause PTL, PPROM, F. compromise 3. ANC should be delayed till the symptoms improve 4. Separate room, dedicated team, appropriate PPE. dedicated equipment 5. Delivery timing depend upon: Mother's clinical status G. age & F. well-being. 6. Mode of delivery based on obstetric indications 7. Regional anasthesia by epidural or spinal 8. The placenta is treated as biohazardous waste 9. Breast feeding not recommended if the mother is severely or critically ill ABOUBAKR ELNASHAR  For CONID 19 AND Pregnancy: The following statements are correct except A. Increased risk of DVT during pregnancy B. It is not sexually transmitted C. Corticosteroid is indicated between 24+0 &33+6 w in patients at high risk of PTL within 7 days D. Oxygen therapy for fetal resuscitation is recommended E. Delayed cord-clamping is unlikely to increase risk of transmitting virus from infected mother to fetus ABOUBAKR ELNASHAR

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