[CG] Acute Management of Obstetric patients with COVID-19

Warning

Risk factors for hospital admission with COVID-19 infection in pregnancy. Risk factors that appear to be associated with hospital admission with COVID-19 illness include:

  1. Black, Asian or minority ethnicity (BAME)
  2. Overweight or obesity BMI>30kg/m2
  3. Pre-existing comorbidity (diabetes, chronic hypertension, cardiac disease and organ transplant)
  4. Maternal age >35 years
  5. Living in increased socioeconomic deprivation
  6. Working in healthcare or other public-facing occupations.

Women of BAME background should be advised that they may be at higher risk of complications of COVID-19; we advise they seek advice without delay if they are concerned about their health

Clinicians should be aware of this increased risk, and have a lower threshold to review, admit and consider multidisciplinary escalation of symptoms in women of BAME background

There is growing evidence that pregnant women may be at increased risk of severe illness from COVID-19 compared with non-pregnant women, particularly in the third trimester. The overall risk of death remains very low.

Pregnant women should be advised to call their midwife or maternity assessment unit/triage unit should they receive a positive COVID-19 result. The VTE risk assessment form should be updated with the positive result and VTE prophylaxis considered if they have other risk factors present. Women should be advised to stay well hydrated and active, they should contact if mobility reduces due to symptoms in order to further update the VTE risk assessment and to assess the need for medical review.

How should a woman requiring hospital admission with symptoms suggestive of COVID-19 be investigated?

If the woman attends with a fever, investigate and treat as per guidance on sepsis in pregnancy (sepsis guideline).

Testing for COVID-19 should be arranged in addition to blood cultures

While pyrexia may suggest COVID-19, do not assume that all pyrexia is due to COVID-19. Consider the possibility of bacterial infection and perform full sepsis-six screening and administer intravenous antibiotics when appropriate. abx guideline

Consider bacterial infection if the white blood cell count is raised (lymphocytes usually normal or low with COVID-19) and commence antibiotics.

Women should be tested for COVID-19 if they have:-

  • A loss of, or change in, normal sense of taste or smell (anosmia) in isolation or in combination with any other symptoms of COVID-19.
  • Clinical/radiological evidence of pneumonia.
  • ARDS.
  • Fever ≥37.8°C AND at least one of the following: acute persistent cough, hoarseness, nasal discharge/congestion, shortness of breath, sore throat, wheezing or sneezing

Radiographic investigations should be performed as for the non-pregnant adult; this includes chest X-ray and computerised tomography (CT) of the chest.

  • Chest imaging, especially CT of the chest, is essential for the evaluation of the unwell woman with COVID-19 and should be performed when indicated, and not delayed because of concerns of possible fetal exposure to radiation, as maternal wellbeing is paramount

The diagnoses of pulmonary embolism and heart failure should be considered in women with chest pain, worsening hypoxia or a respiratory rate >22 breaths/min (particularly if there is a sudden increase in oxygen requirements), or in women whose breathlessness persists or worsens after expected recovery from COVID-19.

Consider additional investigations to rule out differential diagnoses – e.g. electrocardiogram (ECG), CT pulmonary angiogram, echocardiogram, etc

Antepartum cardiotocography (CTG) should be performed daily ≥ 28+0 weeks gestation and considered in women of ≥ 26+0 gestation. CTG’s carried out before 28 weeks should be performed and interpreted with caution, the decision to do so must be made on an individual basis by a senior obstetrician.

How should a woman with suspected/confirmed COVID–19 who is clinically deteriorating be cared for?

The priority for medical care should be to stabilise the woman’s condition with standard therapies.

Hourly observations should include respiratory rate and oxygen saturation, monitoring both the absolute values and trends.

  • Escalate urgently if any signs of decompensation develop.
  • Young, fit women can compensate for a deterioration in respiratory function and are able to maintain normal oxygen saturations until sudden decompensation.
  • Signs of decompensation include an increase in oxygen requirements or FiO2 > 35%, an increasing respiratory rate >25/min despite oxygen therapy or rapidly increasing respiratory rate despite oxygen therapy, an acute kidney injury (reduction in urine output) or drowsiness even if the saturations are normal.
  • Titrate oxygen flow to maintain saturations >94-98% escalating with e.g. nasal prongs, masks, high flow nasal oxygen, CPAP, IPPV, ECMO
  • Do not start antibiotics unless additional bacterial infection suspected. Bacterial (rather than viral) infection should be considered if the white blood cell count is raised (lymphocytes are usually low with COVID-19) and antibiotics should be commenced. Even when COVID-19 is confirmed, remain open to the possibility of another co-existing condition.
  • Suspected COVID-19 should not delay administration of therapy that would usually be given (e.g. intravenous antibiotics in woman with fever and prolonged rupture of membranes).

MDT planning meeting should be urgently arranged for any unwell woman with suspected/confirmed COVID-19. This should ideally involve a consultant physician, consultant obstetrician, midwife-in-charge, consultant neonatologist, consultant anaesthetist and intensivist responsible for obstetric care. The discussion should be shared with the woman and her family if she chooses. The following considerations should be included:

  • Key priorities for medical care of the woman and her baby, and her birth preferences.
  • Most appropriate location of care (e.g. intensive care unit, isolation room in infectious disease ward or other suitable isolation room) and lead specialty.
  • Concerns among the team regarding special considerations in pregnancy, particularly the health of the baby

All pregnant women admitted with confirmed or suspected COVID-19 should be offered prophylactic low molecular weight heparin, unless birth is expected within 12 hours or there is significant risk of haemorrhage. If there is a suspicion of a VTE when therapeutic dose thromboprophylaxis should be administered.

COVID-19 can be associated with thrombocytopenia. When aspirin has been prescribed as prophylaxis for pre-eclampsia, it should be discontinued for the duration of the infection as this may increase the bleeding risk in women with thrombocytopenia. Women who take LMWH thromboprophylaxis during pregnancy should discontinue this if their platelet count falls below 50 x 109/L and their care should be discussed with a haematologist.

Corticosteroid therapy (with PPI cover) should be given for 10 days or up to discharge, whichever is sooner, for women who are unwell with COVID-19 and requiring oxygen or ventilatory support. If steroids are not indicated for fetal lung maturity, treatment should be with

  • oral prednisolone 40 mg once a day,
  • or IV hydrocortisone 80 mg twice daily,

for 10 days or until discharge, whichever is sooner.

If steroids are indicated for fetal lung maturity, prescribe

  • intramuscular dexamethasone 12 mg 2 doses 24hours apart,
    THEN
  • oral prednisolone 40 mg once a day,
  • or IV hydrocortisone 80 mg twice daily,

to complete a total of 10 days or until discharge, whichever is sooner.

Tocilizumab (interleukin-6 receptor antagonist) has been shown to improve outcomes, including survival, in hospitalised patients with hypoxia and evidence of systemic inflammation (C-reactive protein at or above 75 mg/l). Strongly consider tocilizumab (400 mg/600 mg/800 mg single IV infusion depending on weight) if C-reactive protein at or above 75 mg/l or in ICU.

Ronapreve

Group 1 Patients: Ronapreve™ (Casirivimab and imdevimab) for patients hospitalised due to COVID-19 - Guidance for use in GGC (ggcmedicines.org.uk)

Strongly consider REGEN-COV monoclonal antibodies in those with no SARS-CoV-2 antibodies.
Strongly consider REGEN-COV2 Ronapreve (casirivimab and imdevimab) monoclonal antibodies (2.4g single IV infusion) in pregnant and breastfeeding women as treatment if they are symptomatic, hospitalised with COVID-19 infection, and have no SARS-CoV-2 antibodies

See appendix 1 on how to order test
See appendix 3 on observing for signs of hypersensitivity

Ronapreve is not effective against the Omicron variant - in this clinical situation it is suggested that a MDT discussion take place with infectious disease department

Remdesivir should be avoided in pregnancy and breast feeding unless clinicians believe the benefits of treatment outweigh the risks to the individual.

Hydroxychloroquine, lopinavir/ritonavir and azithromycin should not be used as they are ineffective for treating COVID-19 infection.

Be aware of possible myocardial injury, and that the symptoms are similar to those of respiratory complications of COVID-19.

Apply caution with intravenous fluid management

  • Women with moderate-to-severe symptoms of COVID-19 should be monitored using hourly fluid input/output charts.
  • Efforts should be targeted towards achieving neutral fluid balance in labour.
  • Patients may be significantly fluid depleted
  • Try boluses in volumes of 250–500 ml and then assess for fluid overload before proceeding with further fluid resuscitation

An individualised assessment of the woman should be made by the MDT to decide whether emergency caesarean birth or IOL is indicated, either to assist efforts in maternal resuscitation or where there are serious concerns regarding the fetal condition.

Individual assessment should consider: the maternal condition (including changes in oxygen saturations, radiological changes and respiratory rate), the fetal condition, the potential for improvement following iatrogenic birth, and the gestation. The priority must always be the wellbeing of the woman

If urgent intervention for birth is indicated for fetal reasons, birth should be expedited as for normal obstetric indications, as long as the maternal condition is stable

If maternal stabilisation is required before intervention for birth, this is the priority, as it is in other maternity emergencies (e.g. severe pre-eclampsia).

Antenatal steroids for fetal lung maturation should be given when indicated but urgent intervention for birth should not be delayed for their administration

Consider administering magnesium sulphate cover for fetal neuroprotection irrespective of steroid status, but do not delay to administer the magnesium sulphate if urgent birth is indicated

What are the considerations for antenatal care for women who have recovered from COVID-19?

For women who have recovered from a period of serious or critical illness with COVID-19 requiring admission to hospital for supportive therapy, ongoing antenatal care should be planned together with a consultant obstetrician.

All pregnant women who have been hospitalised and have had confirmed COVID-19 should receive thromboprophylaxis for 10 days following hospital discharge. For women with persistent morbidity, consider a longer duration of thromboprophylaxis.

If women are admitted with confirmed or suspected COVID-19 within 6 weeks postpartum, they should receive thromboprophylaxis for the duration of their admission and for at least 10 days post discharge. Consider extending this until 6 weeks postpartum for women with significant ongoing morbidity.

Women who have been seriously or critically unwell should be offered a fetal growth scan approximately 14 days following recovery from their illness in the first instance, unless there is a preexisting clinical reason for an earlier scan (e.g. fetal growth restriction [FGR]) If the period of hospitalisation is before 30 weeks gestation, organise further scans at 32 and 36 weeks. If admitted after 30 weeks, scan after 14 days, further scans should then be organised at 2-4 week intervals, taking into account gestation and other risk factors

What are the considerations for labour and birth for women who have recovered from antenatal COVID-19?

For women who have recovered following a hospital admission for serious or critical COVID-19 illness needing supportive therapy, place of birth should be discussed and planned with the woman, her family, if she wishes, and a consultant obstetrician. A personalised assessment should take into consideration fetal growth and the woman’s choices.

Appendix 1: Procedures for SARS-CoV-2 antibodies (anti-Spike antibody) in GGC

  • The process for sending samples for S-antibody testing is as follows:
    Sample type is a yellow (ochre) top tube.
  • IgG Spike antibody testing is provided from the Biochemistry Department at the QEUH.
  • Samples at sites other than QEUH should be sent to the local lab for forwarding to QEUH Biochemistry Dept.
  • Samples will be run Mon-Fri 9am – 5pm and Sat-Sun 9am-1pm.
  • Results will be provided the same day for samples received between these times. Samples received after 5pm at the QEUH will be analysed the following morning.
  • Requests for this test can be made via TrakCare, the request item is “Covid IgG Spike Protein Assay” this will also enable results to be visible in TrakCare as well as clinical portal.
  • Please note that the Abbott assay used within NHS GG&C has a different cut off to the assay result previously received via NHS Lanarkshire.
    Results <50 U/mL will be reported as ‘Not-Detected’ ≡ Seronegative.

The reason is that if the test shows no antibody response, we will then be in a position to consider the use of Ronapreve (the current RCOG covid guideline states “Strongly consider REGEN-COV2 (casirivimab and imdevimab) monoclonal antibodies (2.4 g single IV infusion) in pregnant and breastfeeding women treatment if they are symptomatic, hospitalised with COVID-19 infection, and have no SARSCoV-2 antibodies (note: currently seeking UK licence).)

Appendix 2: Checklist

Appendix 3: Observing for signs of hypersensitivity to Ronapreve

Group 1 Patients: Ronapreve™ (Casirivimab and imdevimab) for patients hospitalised due to COVID-19 - Guidance for use in GGC (ggcmedicines.org.uk)

There is a risk of hypersensitivity reactions with this drug therefore a member of trained staff should remain with the patient at all times during the infusion and for 30 minutes following the infusion.

Recommendations:

Maternal observations should be taken at the following times

  1. when infusion starts
  2. 5 minutes after infusion starts
  3. 15 minutes after infusion starts
  4. when infusion ends
  5. 30 minutes following infusion

If there are any signs of hypersensitivity then stop the infusion and call for medical help. The anaphylaxis guideline should be followed for management of the patient. Anaphylaxis guideline

References

Version 14.3: updated 11th January 2022. Guidance for healthcare professionals on coronavirus (COVID-19) infection in pregnancy, published by the RCOG, Royal College of Midwives, Royal College of Paediatrics and Child Health, Public Health England and Public Health Scotland.

Last reviewed: 22 February 2022

Next review: 28 February 2023

Author(s): Julie Murphy

Approved By: Covid-19 Tactical Group (Acute)

Document Id: 981