What is Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium?
The COVID-19 outbreak started in December 2019 and, due to many new strains of the virus, it is still ongoing two years later. It’s a virus that can be easily spread by droplets and mutated forms of the virus spread even faster. This makes it extremely important for people at risk to have access to cost-effective protection, information, and care resources. Although COVID-19 primarily affects the lungs, it can also have effects on other parts of the body, which adds to the challenges of managing the disease.
Interestingly, some people can carry the virus without showing any signs of sickness at all, yet they can still infect people around them. Pregnant people, and those who have recently given birth, are typically more susceptible to various infectious diseases. As such, understanding the additional risks faced by these individuals due to their increased vulnerability is vital for improving their health outcomes. Research into these issues is still ongoing.
What Causes Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium?
The illness is caused by a type of ribonucleic (RNA) virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). This virus is part of the Coronaviridae family of viruses. The same family includes the SARS-CoV1 virus, which was responsible for the ‘SARS’ outbreak in 2005, and the Middle East respiratory syndrome coronavirus (MERS-CoV).
There is a lot of discussion about where the virus came from. One theory is that it might have come from wild bats, pangolins (a type of mammal), and/or seafood.
The virus spreads through droplets in the air and enters the respiratory tract. It attaches to something called ACE2 receptors on human cells. This attachment allows the virus to enter the cells. Once inside the cells, it starts to multiply and unfold a series of inflammation/actions which leads to the typical respiratory symptoms of the disease.
Risk Factors and Frequency for Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium
Based on the latest data from the Centers for Disease Control and Prevention (CDC), as of December 2021, around 150,000 pregnant women in the United States have contracted COVID-19. The CDC shares this data through their website and regular reports.
Of these women, approximately 25,000 were hospitalized and about 600 required intensive care. Sadly, around 250 women passed away due to the disease. The majority of infected women were between the ages of 25 to 29, closely followed by those between 30 to 34. The highest number of infections were reported among white, non-Hispanic women, and Hispanic women.
Looking at available birth data, out of about 38,000 live births, approximately 4,000 were preterm births. When newborns were tested, about 150 of nearly 3,300 tested positive for COVID-19 during their birth hospitalization.
Interestingly, roughly 40% of the pregnant women surveyed had received full vaccination – either a two-dose series of mRNA-1273 or BNT162b2, or a single dose of the Ad26.COV2.S vaccine.
International data, which also includes some data from the US, shows that preterm birth was the most common negative outcome globally. Around 3.7% of over 4,000 newborns tested positive for COVID-19 worldwide, which is less than half of the rate reported in the updated CDC data for the USA.
Signs and Symptoms of Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium
Pregnant women with COVID-19 often experience symptoms like fever, shortness of breath, and cough. Usually symptoms of an upper respiratory infection appear in the first week, followed by lower respiratory symptoms if the infection worsens. Other symptoms can include heart palpitations, fainting, diarrhea, and stomach pain.
In some cases, the first sign of COVID-19 might be a pregnancy-related complication. However, because these complications aren’t unique to COVID-19, it might be challenging to diagnose the virus retrospectively.
As a part of the diagnosis process, doctors will likely consider a patient’s recent travel history, considering the current pandemic situation. Whether or not the patient was in contact with someone who had COVID-19 is another crucial piece of information. This contact history will influence decisions related to quarantine, severity risk assessment, and exploring the possibility of post-exposure prevention.
- Travel history
- Contact history
Doctors should also ask about a patient’s history with the COVID-19 vaccine and previous infections. Patients who are unvaccinated or not fully vaccinated are at a higher risk for developing severe COVID-19. It’s also essential to know when the patient received their last vaccine dose and their history with the illness. This information helps decide the timing for their next vaccine.
A patient’s health history, especially any chronic diseases, influences their risk level for severe illness. People with a higher risk for severe illness include patients with cancer, kidney disease, liver disease, chronic respiratory diseases, recipients of stem cell transplants, obese individuals, and people with diabetes and high blood pressure. This risk category also includes women older than 25, people living in areas with high transmission rates, low vaccination rates, and in regions where social distancing isn’t possible, and individuals from specific racial minority groups (Black, Hispanic, American Indian and Alaskan).
Physical exams for COVID-19 patients can range from showing no abnormalities in asymptomatic individuals, to signs of severe respiratory distress syndrome in severe cases. Additionally, the physical examination might indicate a high body mass index (BMI) (>30 kg/m2), signs of chronic steroid use, and signs of liver disease as additional risk factors for poor outcomes.
Common findings during a respiratory examination include rapid heart rate, rapid breathing, below-normal levels of oxygen, heavy use of muscles to breathe, and abnormal lung sounds. Chest pain, coughing up blood, and swelling in one lower leg could suggest a blood clot. Irregular heart rhythms, low blood pressure, and swelling in the extremities could lead to an evaluation for heart dysfunction.
From the pregnancy perspective, a patient may experience abdominal pain, progressive uterine contractions, leaking fluid vaginally, and a dilated cervix – the classic signs of early labor. A sensitive abdomen, fewer baby movements, and abnormal fetal heart rate patterns may all indicate a placental abruption, another complication associated with COVID-19, though this connection is still being studied.
Testing for Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium
When suspecting COVID-19, the best test currently available is the RT-PCR, a test using samples taken from the nose or throat. This test can also be run on samples like placental tissue or cord blood, but it is known to work best with respiratory samples. There’s also an antigen test, which while less sensitive, is very specific to the COVID-19 virus.
Diagnosing a pregnant patient with respiratory distress can be challenging, as there are many potential causes. This would call for a group of multidisciplinary medical professionals to assess the patient, due to the complexity and potential complications of COVID-19. If necessary, a pregnant patient could undergo a CT scan or X-ray. Even though these tests involve some radiation, they should not be avoided if necessary for her health.
COVID-19 can increase the risk of developing blood clots in the lungs, known as pulmonary embolism. Just like in non-pregnant individuals, a pregnant patient would be evaluated for any symptoms of embolism. Tests like a bedside venous ultrasound of the lower extremities may be useful for identifying signs of blood clots. A lung ultrasound following the ‘BLUE’ protocol can also be useful, as it can help diagnose other potential causes of respiratory distress like pulmonary edema, pneumonia, or even pneumothoraces.
Several blood tests can also be helpful when assessing a patient with suspected COVID-19. A complete blood count can show signs typical of viral illness, such as decreased white blood cells. This test could also indicate a secondary bacterial infection if the patient has increased numbers of white blood cells. A test called the neutrophil-lymphocyte ratio can help predict the patient’s prognosis, with high ratios often associated with worse outcomes.
Liver and kidney function tests can also provide valuable information. Elevated levels of transaminase, an enzyme found in the liver, may suggest that the liver isn’t working as well as it should. Certain medications like Remdesivir and tocilizumab can also raise transaminase levels, so there may be a need to adjust the doses if levels rise too much. The kidney function test can detect early signs of kidney injury.
In pregnant patients, using the D-dimer test to guide decisions around imaging isn’t as useful. This is due to the fact that the value of D-dimers can have limited significance when evaluating soon-to-be mothers. Assessing the levels of certain substances like IL-6, CRP, and ferritin can help measure how much inflammation the patient has, which is helpful for making treatment decisions.
If the patient presents with symptoms suggesting heart inflammation, known as myocarditis, an electrocardiogram, echocardiogram, and blood tests on heart enzymes can provide helpful information.
Lastly, from an obstetric point of view, a mother-to-be with COVID-19 pneumonia can have a cardiotocography test to evaluate how well the baby is doing. Depending on the situation, an ultrasound or MRI can be performed to measure the length of the cervix (to check for signs of preterm birth) and to assess the age of the fetus.
Treatment Options for Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium
Caring for a pregnant woman who has COVID-19 involves a team approach, including experts in pregnancy care, lung care, and newborn care. This team decides whether to use different medicines, while ensuring that the expectant mother is informed of the potential risks and benefits.
If a pregnant patient has COVID-19, making sure she has enough oxygen is crucial, not only for her but also for her baby. The need for additional oxygen or special devices to help with breathing is decided based on the mother’s needs. Different medicines such as Remdesivir or monoclonal antibodies might be recommended to prevent the disease from getting worse. Any decision to provide these treatments is based on a careful assessment of their potential benefit and risks.
Some other treatments, such as Tocilizumab or sarilumab, which are used for patients with rapidly worsening symptoms, and Baricitinib and tofacitinib, are not generally recommended for pregnant patients. However, the final decision should be made after a thoughtful discussion with the patient or her family, especially when the patient’s condition is rapidly deteriorating.
Anticoagulation, or blood-thinning medicines, may be used in hospitalized pregnant patients suffering from COVID-19. Pregnant mothers should receive anticoagulation just like non-pregnant individuals do. However, this treatment usually doesn’t continue once the woman checks out of the hospital. When giving birth or experiencing vaginal bleeding during pregnancy, the risks and benefits of these medicines must be considered.
During the care of pregnant COVID-19 patients, helping them change positions to improve oxygen levels can be challenging, especially in late pregnancy. If proning, or lying face down, is not possible due to the size of the pregnant belly, lying on the left side may be an alternative.
If a pregnant woman with COVID-19 requires hospitalization, she should be admitted to a hospital equipped to monitor her and her baby as needed. Her form of delivery should be decided following the usual determinants, regardless of her COVID-19 status. Having COVID-19 alone is not a reason to perform a Cesarean section. If needed, steroids can be administered for the maturity of the baby in the same way as is done in non-pregnant COVID-19 patients.
Postpartum, it is important that decisions regarding the management of the mother and child are made together. This includes decisions about breastfeeding, mother-child separation due to severe infection or high risk for the newborn, and consideration of other drugs passing through breast milk.
Mothers with symptoms may choose to keep away from their newborns for a period of 10 days if the illness is mild or moderate, and for 20 days if it’s severe. COVID-19-positive, yet asymptomatic newborns should have a follow-up check after two weeks, even if discharged earlier. Breast pumps can be provided to encourage expression of breast milk. When together, mothers should wear masks but not their newborn. Between feedings, keeping a distance of six feet can minimize the newborn’s exposure.
Finally, caring for a mother’s mental health is crucial, as there is increased risk of anxiety and depression, among other mental health issues, after having COVID-19. Therefore, having at least one postpartum screening for mental health is advisable.
What else can Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium be?
When doctors examine a patient, they consider several possible explanations for the patient’s symptoms. This list of explanations is known as a differential diagnosis. In cases involving pregnant patients who present symptoms similar to those of COVID-19, there are several possible differential diagnoses to consider:
- Atypical Pneumonia: Conditions like influenza, mycoplasma pneumoniae, and pneumocystis carinii pneumonia can show similar symptoms to COVID-19 in pregnant patients.
- Venous Thromboembolism: This condition involves a blood clot in a vein, which may cause severe respiratory distress. This can be one of the main reasons for significant heart and lung issues, rather than severe pneumonia alone.
- Peripartum Cardiomyopathy: This is a type of heart failure that can occur during the last part of pregnancy or just after delivery. Patients may show signs of acute respiratory distress, which might be mistaken for COVID-19.
- Heart Failure: Various heart issues, including myocarditis and stenotic heart disease, can show symptoms like COVID-19. Therefore, doctors should perform assessments like an electrocardiogram and a echocardiogram to identify any heart dysfunction.
- HELLP Syndrome: This severe pregnancy complication can manifest with symptoms similar to COVID-19. It’s essential to manage this condition carefully to ensure the safety of both the mother and the baby.
Other symptoms not related to the lungs will have their own set of differential diagnoses. It’s also important to note that the factors to consider when diagnosing a patient with COVID-19 are not affected by pregnancy status.
What to expect with Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium
Women who recover from COVID-19 during pregnancy can typically expect to have no further complications in their pregnancy. Normally, there’s no need to change their due date just because they had COVID-19. However, those in the later stages of pregnancy may have a slightly higher risk of delivering their babies prematurely, experiencing a stillbirth, developing high blood pressure related to being pregnant (pre-eclampsia), or experiencing the placenta starting to separate from the uterus too early (placental abruption). However, it’s important to note the overall risk of these outcomes is always changing as more research is done.
After recovering from an acute episode of COVID-19, some pregnant patients may still have symptoms that persist for more than a month, which is often referred to as “long COVID.” The most common lingering symptoms tend to be fatigue, aching joints, and chest pain.
If a pregnant patient experienced a severe case of COVID-19 or developed acute respiratory distress syndrome (a severe lung condition), they could be at a higher risk of developing fibrotic sequelae, which is when parts of the body become hardened due to scarring.
Possible Complications When Diagnosed with Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium
The potential complications of COVID-19 during pregnancy can impact both the mother and the unborn baby. For the mother, these complications may include acute respiratory distress syndrome, pulmonary embolism (a condition where a blood clot forms in the lungs), arrhythmias (irregular heartbeats), and placental abruption (when the placenta separates from the uterus before the baby is born). For the baby, complications can result in preterm birth or stillbirth.
Regardless of whether these complications are managed medically or surgically, the management strategies would be similar to those employed in non-COVID-19 cases. Future patients need to be informed about the possibility of these complications in advance.
Highlighted Complications:
- Mother: Acute respiratory distress syndrome
- Mother: Pulmonary embolism
- Mother: Arrhythmias
- Mother: Placental abruption
- Baby: Preterm birth
- Baby: Stillbirth
Preventing Prevention, Evaluation, and Management of Coronavirus (COVID-19) in Pregnancy and Puerperium
It is important for pregnant women to understand that pregnancy is a condition that potentially carries a higher risk of complications. It’s possible to help prevent COVID-19 with the right daily habits such as keeping a safe distance from others, staying clear of crowded places, washing hands often, wearing a mask properly, getting fully vaccinated and receiving any necessary booster shots. To reduce risk even further, it’s crucial to stay away from friends or co-workers who might be showing signs of illness, which could point to a viral infection. Research has shown that regular hand washing can be particularly effective in limiting the transmission of COVID-19.
In addition, once the baby is born, following correct breastfeeding practices is also very important. Pregnant women should be informed that there’s a preventative treatment available if they’re exposed to COVID-19. They should also make sure to keep any other existing health conditions under control with the medication prescribed to them. This makes managing any possible diseases less complicated.
