Updated: Jan 29
In Conversation with Dr. Rema Nagpal,
Pediatrician and Neonatologist
Associate Professor at BJ Medical College and Sassoon General Hospital, Pune
The information given is as per the situation on August 23rd,2020.
1. What does a COVID19 positive pregnant woman need to be aware of? What is the regular medical procedure? How can they protect themselves and the fetus and people in contact with them?
Most pregnant mothers are likely to have mild or moderate flu-like symptoms, while those with severe symptoms need to be treated similarly to other severely affected adults. An infection with the virus is unlikely to affect the continuation of pregnancy.
While early in the course of the disease pandemic, there seemed to be an increased propensity by Obstetricians to perform Cesarean Sections, current guidelines indicate that Cesarean Sections need to be performed for ‘obstetric’ indications only, and not merely because a mother has been infected with the virus.
Pregnant women from Black, Asian and Minority ethnicity (BAME) backgrounds have been found to have a greater need for hospitalization. Measures like regular exercise, a healthy diet and Vitamin D, Iron and Folic Acid intake (that is usually recommended during pregnancy) should continue, as per guidelines.
Routine antenatal care should not be forgotten and pregnant women should contact their obstetric care givers on the modalities to be followed in case they need to go to hospital. Antenatal transmission or vertical transmission from the mother to the baby before delivery is extremely rare, and there are very few reported cases of possible transmission.
2. How do the gynaecologists handle such situations and approach from a medical professional perspective? Are there changes in regular medical procedures in current times?
The National bodies in each country have developed National Guidelines for the Obstetric Care providers on how to handle pregnant women with symptoms suggestive of COVID 19.
In India, the Indian Council of Medical Research (ICMR) and the Federation of Obstetric and Gynaecological Societies of India (FOGSI) have similar National Guidelines. The pregnant mother needs an antenatal follow up at regular intervals in each trimester, with antenatal ultrasounds and blood tests. These could be tailored by the maternal care provider, to a minimum. The obstetrician will advise pregnant mothers on when and how to visit hospitals for their antenatal checks, precautions to be taken, and also undertake telemedicine services. The aim of the hospital and the obstetrician would generally be to avoid transmission risk of acquiring a COVID infection, when a pregnant woman visits hospital.
During the labor and delivery period, intra partum services need to be provided in a way that is safe for the mother and baby, with provision of emergency obstetric, anaesthetic and neonatal care where indicated.
As regards the need for Cesarean vs vaginal births, there is no evidence to indicate that Cesarean sections prevent spread of COVID infections. Therefore, the current guideline from WHO recommends normal vaginal delivery, unless there is a clear cut obstetric/fetal indication (like e.g. fetal distress) for a cesarean section delivery.
The ICMR and WHO have clearly laid out guidelines for infection control practices that hospitals follow to minimise risk of transmission of COVID in a hospital.
3. Are there any delivery, post-delivery complications for those who are COVID positive?
Once a pregnant woman is admitted in labour, a risk assessment is undertaken, to determine her likely risk of being infected, and a COVID test may be carried out depending on the existing hospital protocol. If the mother has a likely high risk of being COVID positive, or she actually tests positive and is in labor, as per the hospital policy, she will be isolated to either a COVID section of the hospital, or to the area of the hospital where suspect cases are kept. The mother is advised on hand hygiene and respiratory etiquette including wearing a surgical mask, while health care workers also take precautions in terms of wearing the Personal Protective Equipment (PPE) kit.
If the mother has symptoms of Severe Acute Respiratory Infection (SARI) before or after delivery, appropriate medical attention should be sought.
In the postnatal period, there are no particular diet restrictions that need to be followed by the mother, and chicken, eggs etc can be eaten if so desired by the mother. The only absolute precautions to be taken by the mother are hand hygiene, respiratory protocols and mask hygiene, which mothers should rigorously follow while in hospital.
4. We hear many cases where pregnant women test positive during routine check-ups at hospital before delivery? Is there an actual trend of higher positive cases or is it just that we hear only about them?
There is no evidence to suggest that pregnant women are more likely to contract COVID 19 infections, compared to the general population. But pregnancy alters the body immune system, and response to infections in general, and therefore, pregnant mothers need to take appropriate precautions like good hand hygiene practices, and good respiratory etiquette. Pregnant women > 35 years of age, with co-morbidities like obesity, asthma, hypertension or heart disease need to be more careful, because they are at greater risk for the need for hospitalization. Overall, pregnant women do not appear to have a worse outcome or consequences than the general population.
5. Are babies of COVID positive mothers testing positive?
Yes, some babies are testing positive. The testing protocol has been laid out for babies born to COVID positive/suspect mothers. If the mother is positive, the baby is tested at 24-48 hours after birth, by nasopharyngeal swabs for RT-PCR.
If the baby is well and COVID negative, the option could be given to care givers to take the baby home with a healthy care giver (since mother is positive). A repeat test is not essential, if baby keeps well.
If the baby is positive, the baby is kept with the mother, if the mother is well enough to look after the baby. The baby may be discharged, if she keeps well even after a period of observation, as decided by the treating physician.
If the baby tests positive and needs some support and medication, appropriate intensive care services will need to be provided.
However, COVID 19 in the newborn appears to be relatively mild disease. Babies seem able to overcome the disease, though there may be exceptions which are uncommon.
6. What kind of symptoms do neonates and infants demonstrate which could indicate COVID? What needs to be done?
Neonates and infants < 1-year age are a vulnerable population. Babies may develop respiratory distress, increasing Oxygen requirement, fever, bluish discolouration of the fingers and toes, due to cyanosis, poor feeding and lethargy. Parents will need to seek medical attention.
7. Can a COVID positive mother nurse their baby?
So far, current evidence does not indicate that the COVID virus can be transmitted through breast milk. Therefore, the benefits of breast milk far outweigh the risks of virus transmission. The main risk for infants during breastfeeding is the close contact with the mother, who is also likely to share infective airborne droplets. Mothers need to take the following precautions while breast feeding their baby:
o Keep the baby at a distance of 1 meter or more form mother, except at the time of breast feeding.
o Mother should wash her hands before and after touching the baby.
o Mother should wear a mask at all times
o She should avoid coughing or sneezing while feeding the baby.
o All the surfaces in the mother’s room should be disinfected frequently.
o If the mother is too unwell to feed, then alternate feeds like donor breast milk, milk through a milk bank or formula feeds could be given.
If the mother takes due precautions of hand hygiene, always wears a mask while handling her baby, and cleans and washes her hands frequently, then it is unlikely that the baby will catch an infection.
I would like to add, that it is not safe to place a mask on a baby, or on any infant or toddler < 2 years age.
8. If both are negative, what precautions do they need to take being in the hospital.
If the mother and baby are both fortunately negative, the similar precautions will need to be taken – frequent hand hygiene, mother should have a mask at all times, respiratory etiquette, surfaces should be kept clean. Early discharge is advised. Parents/mother is advised to return to hospital in case of fever, cough etc in either the mother or the baby. The mother is advised to ‘home quarantine’ for a period of time as recommended by the discharging physician.
9. Any last tips for pregnant women? and once the baby is born?
i. As mentioned earlier, hand hygiene at all times, whether through proper hand washing or using an alcohol based hand rub (>70% alcohol), proper respiratory etiquette and wearing of masks, physical distancing, and minimal touching of face are crucially important in this pandemic. The mask worn by the mother should cover the mouth and nose.
ii. Clean breast with soap and water if the mother has been coughing before feeding. If she has not been coughing, washing the breast every time prior to feed is not essential.
iii. Giving Breast milk remains the best option. Breast feeding has protective antibodies, and COVID positive mothers can also breast feed, provided appropriate hygiene is ensured. Breast milk does not transmit the virus.
iv. Immunization must be given as per the National Schedule of Immunization of each country.
v. Babies do get infected, but the number of ‘critically sick’ newborns with COVID, is fortunately, very few in number.
vi. Vertical transmission i.e. Antenatal transmission of the COVID virus, from mother to baby, is fortunately, very rare.
vii. Once discharged from hospital, it is advisable for the mother and baby to ‘home quarantine’ for a period of 10-14 days.
Dr. Rema Nagpal is an Alumnus of the Armed Forces Medical College, Pune. After completing her studies at AFMC, she did Short Service Commission in the Army Medical Corps. She did her post graduation in Pediatrics in 1994 from AFMC, and went on to specialize in Neonatology in India and in Australia. Currently, Dr. Nagpal works as an Associate Professor at BJ Medical College and Sassoon General Hospital, Pune, in the Neonatal Intensive Care Unit, which is a 60 bedded unit. This NICU is a State-of-the-Art unit, established as a Public Private partnership, and one of its kind in the State of Maharashtra.
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