Intended for healthcare professionals

Practice Covid-19 Guideline Watch

Covid-19 and pregnancy

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1672 (Published 04 May 2020) Cite this as: BMJ 2020;369:m1672

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Guideline: Coronavirus (COVID-19) Infection in pregnancy

Published by the Royal College of Obstetricians and Gynaecologists (RCOG), with input from the Royal College of Midwives, the Royal College of Paediatrics and Child Health (RCPH), the Royal College of Anaesthetists, and the Obstetric Anaesthetists’ Association.

This summary is based on version 8 of the guideline, published on 17 April 2020 (https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-17-coronavirus-covid-19-infection-in-pregnancy.pdf)

Why is the guideline needed?

Immunological changes during pregnancy, particularly in the third trimester, make women more susceptible to severe symptoms from viral infections, as seen in studies of flu, severe acute respiratory syndrome, and Middle East respiratory syndrome.

However, case reports of pregnant women with covid-19 suggest that the pattern of disease severity in these women is similar to that of the general population. To date, data do not show increased risk of miscarriage, early pregnancy loss, or teratogenicity. Vertical transmission is considered “probable,” however, and cases of preterm birth have been reported.

Pregnant women were placed in the “vulnerable group” by the UK’s chief medical officer on 16 March 2020.1

The aim of the guideline is to support health professionals to provide safe care for pregnant women, whether they have suspected or confirmed covid-19, or are asymptomatic.

How was the guideline developed?

The guideline was developed and is updated using “a combination of available evidence, good practice, and expert advice.”

Full details of the methodology, including information on patient and public involvement, are not included in the guideline.

What does the guideline cover?

The guideline summarises the available evidence on the effects of covid-19 on pregnant women and fetuses. It provides recommendations on the care of pregnant women with suspected or confirmed covid-19 in the antepartum, intrapartum, and postnatal stages.

The guideline does not cover preconception care, fertility treatment, or recommendations for continuing work, but information is available through other guidance on the RCOG website.

What are the key recommendations?

  • Routine antenatal and postnatal care is considered essential. Women should attend appointments unless they have suspected or confirmed covid-19, and self-isolation is required in accordance with national guidelines. The number of visits may be reduced at the discretion of the maternity unit.

  • Consider differentials to covid-19, such as pulmonary embolism and sepsis.

  • The risk of venous thromboembolism is shown to be increased in people with covid-19, and pregnancy is a known hypercoagulable state. Refer to the full guidelines for details on the additional circumstances and considerations when prescribing low molecular weight heparin in pregnant women.

  • Health professionals should inquire about mental health during every consultation and connect women to relevant resources, if required. Assessment of safeguarding may be more challenging, but usual referrals should not be delayed.

Antenatal care

  • Carbon monoxide monitoring should be suspended.

  • For confirmed cases of covid-19, refer women to antenatal ultrasound services for fetal growth surveillance 14 days after symptom resolution.

  • After 28 weeks, social distancing should be observed more stringently for all pregnant women.

Intrapartum care

  • Women are encouraged to have an asymptomatic (no symptoms in the past seven days) partner, friend, or relative present during the birth.

  • Radiology investigations should be performed in line with guidelines. Concerns about the welfare of the fetus should not delay investigation.

  • Continuous electronic fetal monitoring is recommended during labour for all cases of suspected or confirmed covid-19.

  • Healthcare providers should wear appropriate personal protective equipment when treating a patient with suspected or confirmed covid-19. In obstetric emergencies, this may cause a delay and the woman and her family should be warned about this possibility at the earliest opportunity.

  • Evidence does not suggest that use of nitrous oxide (Entonox) is an aerosol generating procedure, and it can be used with a single patient microbiological filter.

  • Evidence does not support any particular mode of birth, but birthing pools should be avoided where women have suspected or confirmed covid-19.

  • Steroids for fetal lung maturation have not been shown to cause more harm in cases of covid-19.

Postpartum care

  • Benefits of breastfeeding currently outweigh the risks of passing infection from mother to infant.

  • Mothers who have tested positive for covid-19 and healthy babies do not require separation.

What does other UK guidance say?

  • Public Health England advises all pregnant women to take extra measures in following social distancing. All pregnant women with heart disease (congenital or acquired) are deemed “extremely vulnerable” and additional restrictions are advised.2

  • RCPCH outlines guidance for babies born to mothers with covid-19.

  • Additional guidance on an extensive range of topics is available through the RCOG website.

Anything else?

Evidence on the effects of covid-19 on pregnancy is limited but rapidly evolving. RCOG is updating this guideline frequently with emerging data.

On 20 March 2020 a registry was launched by the UK Obstetric Surveillance System for women admitted with confirmed covid-19 infection.

Oxford University launched a global study on 24 April 2020 to evaluate the effects of covid-19 on pregnant women.

Footnotes

  • This series signposts clinicians to published guidance on covid-19. Key recommendations from highlighted guidelines are presented by The BMJ’s editorial team in abbreviated form. For full recommendations and details, please see the full version of the guideline.

  • Competing interests: none.

This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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