Coronavirus disease 2019, caused by the severe acute respiratory syndrome coronavirus 2, has been declared a pandemic by the World Health Organization. As the pandemic evolves rapidly, there are data emerging to suggest that pregnant women diagnosed as having coronavirus disease 2019 can have severe morbidities (up to 9%). This is in contrast to earlier data that showed good maternal and neonatal outcomes. Clinical manifestations of coronavirus disease 2019 include features of acute respiratory illnesses. Typical radiologic findings consists of patchy infiltrates on chest radiograph and ground glass opacities on computed tomography scan of the chest. Patients who are pregnant may present with atypical features such as the absence of fever as well as leukocytosis. Confirmation of coronavirus disease 2019 is by reverse transcriptase-polymerized chain reaction from upper airway swabs. When the reverse transcriptase-polymerized chain reaction test result is negative in suspect cases, chest imaging should be considered. A pregnant woman with coronavirus disease 2019 is at the greatest risk when she is in labor, especially if she is acutely ill. We present an algorithm of care for the acutely ill parturient and guidelines for the protection of the healthcare team who is caring for the patient. Key decisions are made based on the presence of maternal and/or fetal compromise, adequacy of maternal oxygenation (SpO 2 >93%) and stability of maternal blood pressure. Although vertical transmission is unlikely, there must be measures in place to prevent neonatal infections. Routine birth processes such as delayed cord clamping and skin-to-skin bonding between mother and newborn need to be revised. Considerations can be made to allow the use of screened donated breast milk from mothers who are free of coronavirus disease 2019. We present management strategies derived from best available evidence to provide guidance in caring for the high-risk and acutely ill parturient. These include protection of the healthcare workers caring for the coronavirus disease 2019 gravida, establishing a diagnosis in symptomatic cases, deciding between reverse transcriptase-polymerized chain reaction and chest imaging, and management of the unwell parturient.
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 are the largest group of RNA viruses. COVID-19 has now been declared a pandemic by the World Health Organization (WHO). The elderly are at greatest risk. Current evidence suggests that neither are pregnant women at a greater risk of COVID-19 than other adults, nor is the condition thought to be more severe in them. A case series of 9 pregnant women at term and late preterm (36 weeks and above) reported good maternal and fetal outcomes. However, all these cases had short time intervals between the diagnosis of COVID-19 and cesarean deliveries, and the true impact of the disease on pregnant women should not be extrapolated from this descriptive study. Moreover, when a larger cohort of 147 pregnant patients was evaluated (WHO-China joint mission report), up to 8% of the cohort were either severely ill (respiratory rate ≥30 breaths/min, oxygen saturation ≤93% at rest, or PaO 2 /FiO 2 <300 mm Hg) or 1% critically ill (respiratory failure requiring mechanical ventilation, shock, or other organ failure that requires intensive care). This rate of severe illness in pregnancy was less than that observed during the influenza (H1N1) pandemic. These statistics came from a country that is now recognized globally to be dealing admirably with the COVID-19 outbreak, having gained experience from the 2003 severe acute respiratory syndrome (SARS) epidemic. It is uncertain whether other health systems would experience severe maternal morbidity below 10% or instead severe illnesses in pregnant women closer to 25% as observed in other coronavirus infections such as the Middle East respiratory syndrome (MERS) and SARS. ,
Moreover, SARS-CoV-2 has been shown to have 85% similarity with SARS coronavirus (SARS-CoV) and MERS coronavirus (MERS-CoV). Both the SARS and MERS epidemics had significant adverse effects on pregnant women including preterm deliveries, stillbirths, respiratory complications, and maternal mortality. Preexisting physiological factors such as basal atelectasis from gravid uterus, lower lung reserves (reduced functional residual capacity), and increased oxygen consumption (30%) predispose the parturient to poor outcomes during respiratory illnesses, such as coronavirus pneumonia. However, there is reasonably good evidence to suggest that vertical transmission from the pregnant patient to the fetus is unlikely. , Recommendations are in place for managing suspected or confirmed pregnant patients with COVID-19, ensuring the safety of their neonates, other parturients in the delivery suite, and healthcare workers caring for them. , ,
Disease transmission and case fatality rate (2.3%) are known to be lower in health systems with better systematic pandemic preparedness strategies and experience in managing coronavirus outbreaks. As of March 25, 2020, Singapore has hospitalized 631 COVID-19 cases confirmed by real-time reverse transcription polymerase chain reaction (RT-PCR), 3 of which were pregnant. Of these 631 patients, 160 fully recovered from the infection and were discharged from hospital. There were 2 mortalities from complications owing to COVID-19, 1 of which was an imported patient who was ill before coming to Singapore and admitted to the intensive care unit (ICU) upon arrival. Singapore was taken by surprise during the 2003 SARS epidemic, but it has since built capacity and capability within the country to manage global infectious disease emergencies with standard protocols for nongravid and pregnant patients.
Clinical presentation
COVID-19 can present with a spectrum of clinical manifestations ranging from mild signs and symptoms, such as fever, cough, sore throat, myalgia, and malaise, to severe illness, such as pneumonia with or without acute respiratory distress syndrome (ARDS), renal failure, and multiorgan dysfunction that may require immediate advanced critical care support. Clinical presentations in pregnant patients with COVID-19 could be atypical with normal temperature (56%) and leukocytosis.
Clinical virology
The largest report to date on COVID-19 from China revealed 1% asymptomatic of 72,134 cases. Of the 44,672 cases confirmed by RT-PCR, 8% were aged between 20 and 29 years whereas 87% between 30 and 79 years. There was no further stratification in the 30 to 79 years age group to represent the reproductive age group 30 to 45 years. Of the 44,415 cases with data on clinical severity, 81% were classified as mild, 14% severe (dyspnea, tachypnea, or oxygen saturation ≤93%), and 5% critical (respiratory failure, septic shock, or multiorgan failure). Overall, case fatality was 2.3%, with 8% of patients in the age group of 70 to 79 years, 14.8% in 80 years and older, and 49% among critically ill. More detailed clinical information from 1099 patients revealed that fever was present in 43.8% on admission but developed in 88.7% during hospitalization. Cough was present in 67.8%, but sputum production was observed only in 33.7%, nasal congestion 4.8%, sore throat 13.9%, and diarrhea 3.8%. The median time from illness onset to dyspnea was 8 days, to ARDS 9 days, and ICU admission 10.5 days. Compared with non-ICU patients, ICU patients with COVID-19 were older with comorbidities and had higher temperature; more dyspnea and tachypnea; more leukocytosis, neutrophilia, and lymphopenia; and higher alanine and aspartate aminotransferase, bilirubin, creatinine, procalcitonin, troponin, D-dimer, and lactate dehydrogenase. , ,
Diagnosing coronavirus disease 2019
Confirmation of the disease is done using nucleic acid amplification tests (NAATs), such as real-time RT-PCR. Average RT-PCR testing needs up to 2 hours, but it takes between 6 and 10 hours for completion, or even longer when batch testing is done by laboratories.
Chest imaging
Imaging of the lungs is important in assessing the extent of COVID-19 pneumonia and in follow-up. Evidence on ultrasonographic imaging of the lung in patients with COVID-19 is evolving. In up to 85% of patients, abnormalities are found on imaging during the acute phase. Radiologic features of COVID-19 include patchy infiltrates on chest x-ray (CXR) and ground glass opacities (GGOs) on chest computed tomography (CT) scan. CXRs can be rapidly performed at bedside but may have reduced sensitivity in the early stages of infection. Chest CT scan is more sensitive than CXR ( Figure 1 A and 1 B ), but its widespread use is limited by availability, the practical but no less important consideration of the need for terminal cleaning to prevent nosocomial transmission, and acceptance by pregnant women. On chest CT, multilobar GGOs are most commonly seen, whereas lower lobe consolidation is more frequently observed in patients with severe and prolonged disease ( Figure 1 C and 1 D). Given its relatively untested specificity, its use as a first-line diagnostic tool has been discouraged by the American College of Radiology.
In an epidemic setting where there is very high pretest probability of COVID-19 infection, a positive result on chest CT scan may precede RT-PCR and chest CT may have higher sensitivity for diagnosis. In a case series of 15 pregnant patients with COVID-19 who were exposed to ionizing radiation between 2.3 and 5.8 mGy, all were found to have CT findings of mild disease, which did not worsen with pregnancy. In some circumstances when an earlier diagnosis of COVID-19 would alter the management of an obstetric patient, particularly if the patient is in respiratory distress raising concerns about significant pneumonia or concomitant pathology (eg, pulmonary embolism), CXR, and thereafter chest CT if needed, could be considered. A diagnostic workflow detailing the application of RT-PCR and chest imaging in the assessment of suspected patients with COVID-19 is described ( Figure 2 ). In such instances, abdominal lead shielding may be applied to reassure patients of the minute risks of scatter radiation to the fetus. ,
Differential diagnosis
COVID-19 is primarily a respiratory illness . As our understanding of the diagnostic imaging features of COVID-19 evolves, significant overlap with other viral and atypical pneumonias has been increasingly reported. On CXR, COVID-19 pneumonia often presents with multifocal, bilateral airspace opacification. This distinguishes it from the more common unifocal involvement noted in SARS, but not in MERS. When imaged by CT, the distribution seen in COVID-19 is similar to that noted in other viral and coronaviral pneumonias, such as influenza, parainfluenza, respiratory syncytial virus, and adenovirus. , Even the multifocal GGOs, described in more than 80% of COVID-19 pneumonias, are common features of atypical (eg, Mycoplasma pneumoniae ) and opportunistic (eg, Pneumocystis jirovecii ) pneumonias. , As with other viral pneumonias, lymphadenopathy and pleural effusions are uncommon associated findings. In the later stages of COVID-19, confluent consolidation and interstitial thickening become more pronounced, with up to 20% patients developing features of ARDS. , Given the significant overlap of imaging findings with other acute viral respiratory infections, imaging alone is unlikely to supplant the role of RT-PCR for the primary diagnosis of COVID-19.
Minimizing disease transmission
Person-to-person transmission is now known to occur via fomites, droplets through close proximity aerosols, , and prolonged close contact within a 2-m perimeter. A study revealed that patients can continue to shed the virus as evidenced by positive RT-PCR results for up to 13 days after disease resolution. Stool sample remained positive in 50% of recovered patients. Coronavirus epidemics in the past are known to have occurred with aerosolization from flushing of toilets.
The spread of infection has been reported from asymptomatic patients, thereby rendering early detection and disease containment difficult. There is a possibility of viral dissemination when a patient is forcefully exhaling when in pain during active labor. Hence it is prudent to consider early epidural analgesia for optimal pain control, and unmedicated natural labor should be discouraged. In addition, all healthcare staff attending to women in active labor need to don full personal protective equipment (PPE).
Infection control
In a simulated experiment where aerosols were generated using a 3-jet Collison nebulizer and fed into a Goldberg drum, SARS-CoV-2 could survive on plastic and stainless steel surfaces for 72 hours, cardboard 24 hours, and copper 4 hours. The median half-life of the virus in this simulated aerosol was 2.7 hours (95% confidence interval, 1.65–7.24 hours). In contrast, in a real-world experiment conducted in Singapore, 3 patients in different rooms had surface environmental samples taken at multiple sites, which revealed that bleach disinfection was highly effective in 2 rooms and fomite contamination was common in the third room. Notably, air, PPE, anteroom, and corridor samples were negative. In addition, a case report of emergency intubation in an unsuspected patient subsequently found to have a positive test result for COVID-19 showed that no healthcare workers wearing surgical or N95 masks were infected. In summary, current recommendations for hand hygiene, eye protection, N95 mask, splash-resistant gown, and gloves should be sufficient.
Managing patients with coronavirus disease 2019 in labor
A pregnant woman presenting to the delivery suite or emergency department needs to be triaged based on the presence of maternal and/or fetal compromise ( Figure 2 ). When there is imminent risk, emergency cesarean delivery must be performed. When there are other maternal and fetal conditions requiring early operative delivery, a coordinated team response is initiated for assessment and optimization of maternal oxygenation and infection control measures. Cesarean delivery is advised for maternal indications, such as worsening condition of the mother related to COVID-19 and fulminant preeclampsia, or fetal indications, such as nonreassuring fetal status. When an operative delivery is not planned, pregnant mothers need to be admitted into the delivery suite for detailed assessment, labor pain management, stratification of infection control precautions, and plans for safe delivery of the fetus. In the presence of COVID-19, the threshold for cesarean delivery should be lower than usual so that infection control procedures can be more readily adhered to and disease transmission minimized.
Safe and optimal care of the parturient in the peripartum period requires a multidisciplinary team approach. The healthcare professionals who provide this coordinated care include obstetricians, neonatologists, anesthesiologists, midwives, and support services at the delivery suite. Here, we highlight the acute care perspectives of the parturient, summarize existing evidence, and propose an algorithmic approach for the management of the acutely ill parturient.
Anesthesia in emergency cesareans for pregnant women with coronavirus disease 2019
An emergency cesarean delivery (30-min decision-to-incision interval) mandates a systematic plan and preparedness for minimizing cross-contaminations. Although emergency cesarean delivery needs to be performed as soon as possible, there are instances where the decision to go for urgent cesarean delivery has some lead time. The possibilities of suspected patients with COVID-19 requiring imminent operative deliveries have to be communicated to the operating room team so that they could be conducted in negative-pressure operating rooms.
When a COVID-19 parturient with desaturation (oxygen saturation decreases to ≤93%) presents for emergency cesarean delivery, general anesthesia needs to be administered, which is done with rapid sequence induction (RSI) and tracheal intubation with a cuffed tube. The airway team should don full PPE and powered air-purifying respirator (PAPR). The presence of systemic complications of COVID-19 such as renal failure and disseminated intravascular coagulation might warrant the use of invasive monitoring (intra-arterial blood pressure and central venous pressure).
When the parturient’s oxygen saturation is adequate (94% and above), , regional anesthesia with epidural top-up or single-shot subarachnoid blockade needs to be actively considered instead of general anesthesia to minimize aerosolization and cross-infection during airway management. Where there is a working epidural catheter in place for continuous labor analgesia, administering a top-up with potent local anesthetics (eg, 10–15 mL of 1.5% lignocaine, alkalinized with 8.4% sodium bicarbonate) achieves surgical anesthetic plane with a rapid onset of 3.5 minutes. Rapid sequence spinal anesthesia is described for emergency cesarean deliveries, wherein patients are placed in a left lateral position with supplemental oxygen, and a single-shot subarachnoid blockade is administered by the most experienced prescrubbed anesthetist. The time required for surgical readiness is comparable with that for general anesthesia, and neonatal outcomes are better.
Extubation after general anesthesia should be performed with the same precautions as with intubation. Patients tend be more agitated during emergence from anesthesia and extubation, which could result in increased likelihood of viral dissemination from coughing as compared with the intubation process. During RSI and intubation, patients are anesthetized, hence paralyzed and unable to cough. It is imperative that all operating room personnel wear full PPE until patients are safely extubated and transferred out of the operating room. ,
The disposition for patients with COVID-19 after unplanned cesarean delivery should be decided at the earliest instance. Transferring these patients to the postanesthesia care unit (PACU) might compromise and cross-contaminate other postoperative patients. Provisions should be made for suspected and confirmed patients to recover in the operating rooms where cesarean deliveries were performed. Patients should subsequently be transferred directly to isolation wards after recovery.
The acutely ill parturient
When a parturient desaturates, there are multiple etiopathologies: infective (pneumonia with or without COVID-19), inflammatory (systemic inflammatory response syndrome), cardiogenic (peripartum cardiomyopathy, viral myocarditis), and noncardiogenic pulmonary edema (hypertensive and nonhypertensive pulmonary edema). A stepwise approach for systematic management of the acutely ill parturient is detailed ( Figure 3 ).
