Covid 19 pregnancy RCOG guideline

Question 1

Mode of transmission of SARS-Cov-2

Answer 1

From respiratory droplets or secretions, faeces and fomites (objects)

Vertical transmission: if vertical transmission does occur, it is uncommon.

If it does occur, it appears to not be affected by mode of birth, method of feeding or whether
the woman and baby stay together (rooming in)

Question 2

Effect of covid-19 on pregnant women

Answer 2

Pregnant women do not appear more likely to contract the infection than the general population

Question 3

Symptoms of covid-19 in pregnant women

Answer 3

Mostly symptoms of a mild respiratory illness

Systematic review “PregCOV-19” :
Most common symptoms of COVID-19 in pregnant women were fever (40%) and cough (39%).

Less frequent symptoms were dyspnoea, myalgia, loss of sense of taste and diarrhoea, each present
in more than 10% of women.

Pregnant women with COVID-19 were less likely to have fever or myalgia than non-pregnant women of the same age.

An estimated 74% (95% CI 51–93) are asymptomatic based on studies that reported universal
screening for a total of 162 pregnant women

Question 4

Relationship between gestation and covid-19

Answer 4

Severe illness appears to be more common in later pregnancy.

In the UKOSS study, most women were hospitalised in their third trimester or peripartum. The median gestational age at hospital admission was 34+0 weeks of gestation.

An analysis of women in French hospitals showed that
those in the second half of pregnancy, from 20 weeks of gestation, were five times more likely
to be admitted to ICU than those in the first half of pregnancy

Intensive care admission may be more common in pregnant women with COVID-19
than in non-pregnant women of the same age.

Question 5

Effect of Covid-19 on pregnancy

Answer 5

• 3x higher risk of preterm birth (mostly iatrogenic)

- Increased risk of CS due to maternal/fetal concerns and increase risk of requiring GA

Question 6

Risk factors for hospital admission with COVID-19 infection in pregnancy

Answer 6

1. Black, Asian and minority ethnic (BAME) background - possibly due to socioeconomic factors, response to disease, vitamin D deficiency
2. Being overweight (BMI 25–29 kg/m2) or obese (BMI 30 kg/m2 or more)
3. Pre-pregnancy co-morbidity, such as pre-existing diabetes and chronic hypertension
4. Maternal age 35 years or older
5. Living in areas or households of increased socioeconomic deprivation

The risk of becoming infected is higher in those with increased exposure risk e.g. healthcare workers or other public-facing occupations

Question 7

Specific advice for women of BAME background in UK

Answer 7

Vitamin D supplementation in pregnancy

Question 8

Effect of COVID-19 on the fetus

Answer 8

Currently no evidence to suggest increase in congenital abnormality, neonatal death, still birth

Insufficient evidence to suggest impact on miscarriage

No evidence to suggest risk of FGR but 2/3 of pregnancies with SARS had FGR

Overall data for neonatal outcomes appears to be positive. Small rate of transmission to baby and in general they did well. Rate of admission of term babies to NICU was 10% but 95% of babies born in good condition.

Question 9

Service related impact of covid-19

Answer 9

In the UK antenatal and postnatal visits were reduced.

Study n London found an increase in stillbirth rate but no evidence of covid-19 infection therefore this may be due to other factors eg reduced antenatal care

two women committed suicide and were unable to access help due to covid-19 restrictions

Question 10

Advice regarding provision of ANC during pandemic

Answer 10

• Where possible try to provide same ANC and routine screening
• Recognise that some women may be disadvantaged due to

Question 11

Acute management of Covid-19 in pregnancy.

RCOG 2021

Answer 11

• History and examination
• Triage as mild, moderate (O2 requirement) or severe (NIV/IPPV/ECMO)
• MDT management approach - early involvement of ICU and inform neonatal, anaesthetic and theatre teams in cases where early delivery likely
• Obstetric care and decision making by SMO
• VTE prophylaxis LMWH
• Withold aspirin if taking
• O2 therapy to maintain sats >94%
• If O2 requirement, starts steroids (40mg prednisolone po OD)
• If preterm delivery planned - 2x 12mg dexamethasone IM 24hr apart
• Tocilizumab or Sarilumab in women with CRP > 75 or admitted to ICU.
• Monoclonal antibodies
• Remdesivir only for women who fail to improve on the above

Question 12

Counsel a pregnant patient about the Covid-19 vaccine.

Answer 12

• In NZ Pfizer vaccine most widely available
• Free and widely available
• 2 doses 2-6 weeks apart - now doing boosters from 4 months
• mRNA vaccine - enters host cell but not nucleus, so no interference with persons genetic make-up
• mRNA codes for covid spike protein, which host cells translate to create spike protein
• Body mounts immune response to circulating spike protein
• mRNA broken down in a few days
• 2 doses = 95% effective
• No specific studies looking at vaccine in pregnancy, but data extrapolated from large number of women in USA and UK (275,000 women) - no evidence of any adverse effects on pregnancy or neonate
• Abs have been found in cord blood and breast milk after vaccination - suggesting a role for transfer passive immunity - though true effect not yet elucidated
• Can be given at any time during pregnancy or breast feeding
• General recommendation is for pfizer or modern vaccines, as most evidence available for these vaccines