By Henry P. Mishek and Karen Carlson, MD, FACOG
During the COVID-19 pandemic, professional societies have released clinical recommendations for management of infected patients in several demographics. Unfortunately, there is a lack of reliable data to produce sound management guidelines, especially relating to demographics with nuanced challenges of care like pregnant patients. The lack of evidence supporting the recommendations will likely force obstetricians to make management decisions that have the potential to compromise care for mothers and children. Reduction of visits and isolation could lead to poor maternal and fetal health outcomes, worsening of mental health conditions, and decreased likelihood of sustained breastfeeding.
Since the emergence of the novel coronavirus (SARS-CoV-2) in December 2019, public health authorities and professional societies have been scrambling to develop management guidelines for clinicians to utilize. In the United States, the Centers for Disease Control and Prevention (CDC) distributed their first guidance in late January and have made continual revisions to date, with many professional societies following suit (Donders et al., 2020; Poon et al., 2020; World Health Organization, 2020; American College of Obstetricians and Gynecologists, 2020; Royal College of Obstetricians & Gynaecologists, 2020; Patel & Jernigan, 2020). With a paucity of data to make informed patient care decisions, guidelines can make the best available evidence accessible to physicians on the front lines. These resources are of interest to physicians who care for vulnerable and niche demographics. Pregnant patients, in particular, require nuances of care that need to be addressed in practice guidelines.
OB-GYN professional societies in the United States and United Kingdom have generated practice guidelines based on recommendations from the World Health Organization, CDC, and National Health Service. These recommendations are built upon data from small case reports and retrospective analyses. The lack of sound scientific data, however, has made producing reliable guidance for obstetricians a challenge. For instance, the Royal College of Obstetricians and Gynaecologists (RCOG) suggests that vertical transmission of COVID-19 is probable (Royal College of Obstetricians & Gynaecologists, 2020), while both the American College of Obstetricians and Gynecologists (ACOG) and the International Society for Infectious Diseases in Obstetrics and Gynaecology state that there is no conclusive evidence of vertical transmission (Donders et al., 2020; American College of Obstetricians and Gynecologists, 2020). Variations in guidelines make interpretation of evidence difficult for obstetricians. This may lead to unnecessary risks and compromised quality of care (Woolf et al., 1999).
Currently, it appears that there is limited neonatal and maternal morbidity from COVID-19 infection. Fetal outcomes including rates of miscarriage and growth restriction are difficult to generate. Consequently, professional societies resort to drawing conclusions from the SARS and MERS outbreaks in the early 2000s (Royal College of Obstetricians & Gynaecologists, 2020) or from case reports. A systematic review of cases from Sweden published in April demonstrated only 3% ICU admissions and no fatalities in 108 pregnancies. The ICU admissions involved mothers with other complicating medical comorbidities. Only one of 75 neonates tested positive for COVID-19, and this neonate did well clinically (Zaigham & Andersson, 2020). Still, much remains unclear about maternal and neonatal outcomes based on this one systematic review. This uncertainty can lead to broad generalizations that may not adequately inform and account for patient preferences in individual situations (Woolf et al., 1999). Generalizations are made from necessity because of lack of evidence to suggest otherwise. This may be detrimental to mothers with suspected or confirmed COVID-19 in other ways than direct harm from infection.
In the prenatal period, obstetricians can educate mothers about their pregnancy course and monitor fetal development. In accordance with current guidelines for COVID-19, reduction of antenatal visits is encouraged. Also, implementation of telephone or telehealth follow-up is universally endorsed (Donders et al., 2020; Poon et al., 2020; American College of Obstetricians and Gynecologists, 2020; Royal College of Obstetricians & Gynaecologists, 2020; British Medical Journal, 2020). This could compromise follow-up for mothers who have poor adherence to appointments or have difficulty with technology. Obstetricians lose the face-to-face opportunity to answer questions and establish rapport with the pregnant patient. This may cause undue anxiety and perhaps lead to harm to both the mother and the fetus. Insufficient prenatal care utilization has been associated with insufficient weight gain, prenatal smoking, premature rupture of membranes, precipitous labor, choosing not to breastfeed, and postpartum smoking (Yan, 2017). For mothers who are self-isolating due to suspected COVID-19 infection, it is suggested that growth scans, oral glucose tolerance tests, and secondary care appointments be delayed until after the isolation period (Poon et al., 2020; Royal College of Obstetricians & Gynaecologists, 2020). Realistically, this may mean that some mothers are more likely to opt out of these important components of prenatal care due to compounding socioeconomic barriers. Asymptomatic bacteriuria, gestational hypertension, intrauterine growth restriction, and other pregnancy complications may go unnoticed without the clinical information and education that office prenatal visits afford.
Mental health monitoring is another important component of prenatal care that may suffer. The International Federation of Gynaecology and Obstetrics (FIGO), ACOG, and RCOG (Poon et al., 2020; American College of Obstetricians and Gynecologists, 2020; Royal College of Obstetricians & Gynaecologists, 2020) mention the need for mental health follow-up without specific details. Due to current recommendations, obstetricians may lose opportunities for formal mental health assessments and referrals that would be more likely done in office. Mental health conditions in pregnancy are likely to be exacerbated by the stress induced by COVID-19. These stressors include mass isolation, financial strain, concern for the pregnancy and newborn, anxiety, substance use, and domestic violence (Pfefferbaum & North, 2020). Furthermore, many women are prohibited from having visitors at prenatal ultrasounds. If there is news of a missed abortion or unanticipated findings on an anatomy scan, new mothers must face these challenges on their own without the support of a partner.
As with antepartum care in the pandemic, professional societies are forced to relay information about intrapartum care that is vague and unsupported by evidence. Some guidelines encourage the presence of an asymptomatic birth partner (Royal College of Obstetricians & Gynaecologists, 2020; British Medical Journal, 2020), whereas others state that birth partners should not be permitted in any case to reduce the risk of infection transmission (Donders et al., 2020; Poon et al., 2020). This is relevant to birth outcomes as it has been previously shown that continuous support from a birth partner is associated with lower rates of cesarean and operative vaginal delivery, less use of pain medications, slightly shorter labors, and higher satisfaction (Hodnett et al., 2013). Furthermore, both FIGO and RCOG encourage shortening the second stage of labor by operative vaginal delivery in COVID-19 (Poon et al., 2020; Royal College of Obstetricians & Gynaecologists, 2020). This recommendation is made despite the lack of evidence to assume the fetus is compromised due to maternal COVID-19 infection. Operative delivery does present risks to both the mother and fetus, including fetal and maternal trauma and postpartum hemorrhage. Similar risks must be accounted for in other aspects of intrapartum management.
Delayed cord clamping for confirmed COVID-19 patients is a practice that has been called into question. RCOG recommends continuation of this practice on grounds that the increased time is unlikely to increase infection risk (Royal College of Obstetricians & Gynaecologists, 2020). FIGO and Chinese expert consensus statements instead promote prompt clamping and transfer to the attending pediatric team (Poon et al., 2020; Chen et al., 2020). ACOG does not explicitly condemn the practice of delayed cord clamping and instead assumes continued routine intrapartum care as appropriate. Delayed cord clamping is known to decrease frequency of blood transfusions and iron-deficiency anemia, improve neurodevelopmental outcomes in term infants, and decrease incidence of intraventricular hemorrhage (Bayer, 2016). It is therefore imperative that further studies are done to elucidate the true risk of transmission and neonatal outcomes to ensure decisions are being made in the best interest of the mother and child. It is important to have dependable evidence to integrate with clinical acumen throughout the whole birthing process and postpartum period.
In the immediate postpartum period, close contact between mother and child is integral to establish appropriate bonding and breastfeeding. This presents a significant challenge in mitigating COVID-19 infection risk. Most guidance suggests that the benefits of breastfeeding outweigh the risks of infection (Donders et al., 2020; Poon et al., 2020; British Medical Journal, 2020). Physical distancing of newborn and mother, though, remains controversial. RCOG maintains that COVID-19–positive women and healthy babies not in need of neonatal care should remain together postpartum (Royal College of Obstetricians & Gynaecologists, 2020; British Medical Journal, 2020). Chinese experts suggest that the mother and newborn should be isolated separately until neonatal infection can be ruled out (Chen et al., 2020). FIGO suggests maintenance of contact precautions and PPE until the mother tests negative for COVID-19 by physical distancing of the baby and use of a curtain when the child is in the room with the mother (Poon et al., 2020). The decision on whether to isolate the mother from the child may have lasting impacts. Skin-to-skin contact immediately after birth has been shown to increase the likelihood of effective and sustained breastfeeding (Moore et al., 2016). Benefits of breastfeeding include lower rates of neonatal infection and illness, asthma, and allergies, as well as possible protection against childhood obesity. For mothers, breastfeeding facilitates postpartum weight loss, delays ovulation, and produces positive metabolic changes (Dieterich et al., 2013). These benefits are factors that must be seriously considered when developing practice recommendations.
Another risk in the postpartum period relates to postpartum contraception. The CDC initially discouraged elective procedures (Centers for Disease Control and Prevention, 2020), and many hospital systems in the United States continue to carry out this guidance. Postpartum tubal ligations are considered elective surgeries, and therefore obstetricians may have been unable to perform these for their patients while hospitalized after delivery. This may lead to an increase in short-interval pregnancies in patients who had tubal ligation in mind for postpartum contraception. Shortened intervals between pregnancy have been associated with worsening maternal morbidity and mortality, spontaneous preterm delivery, and increased stillbirth (Schummers et al., 2018).
Clinical practice guidelines help integrate evidence-based practices within individual patient scenarios amidst fast-paced decision-making. Unfortunately, the rapid clinical responses demanded during a pandemic often are not conducive to controlled scientific method. Consequently, recommendations may be generated from small case series and retrospective analyses. Professional societies must advise their members using what little clinical evidence is available. This leads to generalizations that fail to address nuances of care for special patient populations, like pregnant patients. Management guidelines from sound data related to this demographic should be generated to ensure that the safety and preferences of obstetricians and their patients are respected during the COVID-19 pandemic.
Henry Mishek is a fourth-year medical student at the University of Nebraska Medical Center. He hopes to pursue a career as an OB-GYN. Karen Carlson is an associate professor and associate clerkship director in the Department of Obstetrics and Gynecology at the University of Nebraska Medical Center and Nebraska Medicine.
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