Care of the pregnant woman with coronavirus disease 2019 in labor and delivery: anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, care of the newborn, and protection of the healthcare personnel

Abstract

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 (SpO₂ >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.

Keywords: ACE2; ARDS; COVID-19; MERS; SARS; SARS-CoV-2; acute respiratory distress syndrome; acutely ill; coronavirus; coronavirus disease 2019; maternal morbidity; obstetric management; pandemic; pregnancy; severe acute respiratory syndrome; vertical transmission; virus.

Figure 1

Chest imaging in patients with COVID-19 Imaging of 2 patients with COVID-19. A, Contrast-enhanced CT of 1 patient in the axial plane across the lower lobes of the lungs shows patchy GGO in a lobular distribution. Early changes of consolidation are present in the posterior segment of the right lower lobe (arrow). B, Corresponding chest radiograph does not reveal significant abnormality other than a small focus of consolidation in the medial right lower zone (arrow), which would have been easily missed owing to projection adjacent to the right cardiophrenic angle and overlapping rib shadow. C and D, CT pulmonary angiogram of a different patient with severe pneumonia in the axial and coronal planes showing extensive multilobar GGO (arrows) with areas of confluent consolidation (arrowheads) mostly distributed in the posterior and basal regions of the lower lobes. No pulmonary embolism was detected. These findings are not specific to COVID-19 and may be seen in other viral and atypical pneumonias. COVID-19, coronavirus disease 2019; CT, computed tomography; GGO, ground glass opacity. Ashokka. Care of the pregnant woman with coronavirus disease 2019 in labor and delivery. Am J Obstet Gynecol 2020.

Figure 2

Suspected pregnant patient with COVID-19 diagnostic workflow ∗A suspected case of COVID-19 is one who presents with an acute respiratory illness of any degree of severity who, within 14 days before onset of illness, had traveled to any listed countries requiring heightened vigilance or had prolonged close contact with a confirmed COVID-19 patient. ¶ Negative RT-PCR tested in 2 consecutive days, at least 24 hours apart. ∗∗Close monitoring includes social and physical distancing, body temperature monitoring, and assessment of symptoms of acute respiratory illness. Chest imaging includes chest x-ray, chest CT, and lung ultrasound. COVID-19, coronavirus disease 2019; CT, computed tomography; RT-PCR, reverse transcription polymerized chain reaction. Ashokka. Care of the pregnant woman with coronavirus disease 2019 in labor and delivery. Am J Obstet Gynecol 2020.

Figure 3

Stepwise approach for the care of acutely ill parturient At all times, maternal and fetal compromise has to be assessed and acted upon as per standard intrapartum obstetric management. ∗Exclude obstetric contraindication to vaginal delivery. AFE, amniotic fluid embolism; ARDS, adult respiratory distress syndrome; CO, cardiac output measured by noninvasive pulse contour methodology from intra-arterial waveform analysis; ECMO, extracorporeal membrane oxygenation; GA, general anesthesia; LV, left ventricle; RA, regional anesthesia; RV, right ventricle; SpO₂, percentage saturation of hemoglobin with oxygen; SVR, systemic vascular resistance. Ashokka. Care of the pregnant woman with coronavirus disease 2019 in labor and delivery. Am J Obstet Gynecol 2020.