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

Balakrishnan Ashokka, May Han Loh, Cher Heng Tan, Lin Lin Su, Barnaby Edward Young, David Chien Lye, Arijit Biswas, Sebastian E. Illanes, Mahesh Choolani

Research output: Contribution to journalArticlepeer-review

59 Scopus citations

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.

Original languageEnglish
Pages (from-to)66-74.e3
JournalAmerican Journal of Obstetrics and Gynecology
Volume223
Issue number1
DOIs
StatePublished - Jul 2020

Bibliographical note

Funding Information:
We acknowledge the pediatric infectious diseases inputs from Dr Chan Si Min, Pediatrics, National University Hospital Singapore. The authors thank Dr Pradip Dashraath and Dr Wong Jing Lin Jeslyn, Department of Obstetrics and Gynecology, National University Hospital Singapore, for their inputs during the initial discussion about the direction of the manuscript.

Publisher Copyright:
© 2020 Elsevier Inc.

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

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