Daniel H. Singleton, MD, MAS, FAAFP
As the world grapples with the novel coronavirus, SARS – CoV – 2, we must consider the evidence-based care of pregnant and newborn patients. Considerations include 1) changes in the delivery of routine prenatal care, 2) considerations of virus associated risks during pregnancy, 3) risk and mitigation around delivery and the newborn.
- Changes to routine prenatal care – Telehealth is an important mitigation strategy for limiting community spread of COVID 19. We must recognize that social distancing guidelines will disrupt the schedule of routine prenatal care. Telehealth is an important tool for providing access during times when community mitigation strategies are in place. The healthcare team should consider the patient population, availability of internet connectivity, local prevalence of viral illness and availability of staff and PPE resources. This necessitates a cooperative problem-solving approach that includes patient, clinical leadership and staff participation. Telehealth should be used for screening of contact with known positive patients and monitoring patients for development of symptoms of COVID-19. Increased communication between patient and provider will help set expectations and allow more successful implementation while providing needed care.
- Risks during pregnancy – Respiratory illness has been considered a risk factor for increased morbidity and mortality during pregnancy. There is yet little evidence that pregnancy and coronavirus infection together cause increased severe morbidity in comparison to the general population. For pregnant patients with comorbid conditions, their risk appears similar to those with similar comorbidities in the general population. Evidence is lacking for vertical transmission from mother to infant.
- Assessing risk and mitigation around delivery and the newborn – An initial first step is to develop and understand facility policies toward patients under investigation (PUI) or known positive patients. Local and state public health authorities can help provide guidance to frame these policies for local and community needs. CDC recommended PPE should be made available for healthcare workers in contact with PUI and known positive patients.
Algorithmic management of mother and newborn follows different protocols for known positive mothers and PUI mothers. The newborns of known COVID-19 positive mothers should be treated as PUI. The infant PUI should be tested and isolated from healthy newborns. Testing of the newborn PUI should be done at 24 hours of age and repeated at 48 hours by swabbing the mouth and then the nasopharynx with the same swab.
If found positive, then testing should be repeated every 48 hours until there are two consecutive negative tests. If the positive infant is asymptomatic, then there may be frequent outpatient follow up using telehealth when available until day-of-life 14. Discussion on the prevention of household spread from the infected infant are necessary.
The infant testing negative, but whose mother is positive, should be discharged into the care of a healthy caregiver. The mother should maintain social distancing of 6 feet and use hand hygiene and mask for care of infant until one of two things occur. 1) she is afebrile without antipyretics for 72 yours and she is at least 10 days past the onset of symptoms OR 2) she has two consecutive negative COVID-19 tests done at least 24 hours apart. Similar guidelines should be used for visitation to the NICU for by positive mothers.
In the case of mothers that are PUI, the infant is not considered PUI but temporary separation from the mother should be considered until negative resolution of the mother’s pending results. If the mother becomes a known positive, then the infant gains PUI status and should be treated as such.
There are aspects of breastfeeding that should be considered for care of the mother-newborn dyad. There is no evidence to date that is SARS-CoV-2 transmitted through breastmilk. For a mother that is known positive or PUI mothers may express breast milk using appropriate breast and hand hygiene and the milk may be feed by a non-infected caregiver. Direct breastfeeding must be accompanied by strict hand and breast hygiene along with the use of a mask.
Providers must work diligently to adapt to changes in access as the pandemic develops and changes in each locality. This will require greater flexibility in how access to needed care is provided while maintaining appropriate safety for healthcare workers and patients. The increased rates of infection, morbidity, and mortality in communities of color who also represent increased risk of peripartum morbidity and mortality requires that every effort to be made to address access and patient education around risks during the current viral pandemic.
Resources:
The American Academy of Pediatrics (AAP) issues guidance on breastfeeding during COVID-19 pandemic. https://www.aappublications.org/news/2020/04/23/covid19breastfeeding042320
The American Academy of Pediatrics (AAP) issued guidance on infants born to mothers with suspected or confirmed COVID-19. https://www.aappublications.org/news/2020/04/02/infantcovidguidance040220
Coronavirus, A. N. (2019). Practice Advisory [https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019
Discontinuation of Isolation for Persons with COVID -19 Not in Healthcare Settings: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html 5/3/2020