This opinion incorporates recent treatment experiences and insights from Tongji Hospital, deeply integrating the actual clinical situations in the hospital's obstetrics and gynecology and neonatology departments. Presented in a question-and-answer format, it is easy to understand and highly practical. The Tongji expert team urges: During the COVID-19 pandemic, care must be taken for pregnant women and newborns.
This opinion combines the "Diagnosis and Treatment Protocol for Novel Coronavirus-Infected Pneumonia (Trial Version 4)" issued by the National Health Commission on the 27th with the latest "Interim Guidance on Preventing the Spread of 2019 Novel Coronavirus (2019-nCoV) to Others in Families and Communities" issued by the U.S. Centers for Disease Control and Prevention (CDC).
Since December 2019, multiple cases of pneumonia caused by the novel coronavirus have occurred in Wuhan, Hubei Province, and similar cases have also appeared in other parts of my country and abroad. The disease is mainly characterized by fever, fatigue, and dry cough; a few patients also experience nasal congestion, runny nose, and diarrhea, while some cases have no obvious fever. In the early stages of the disease, the total white blood cell count in peripheral blood is normal or decreased, and the lymphocyte count is reduced. Chest CT scans show the imaging features of pneumonia. Pregnant women are in a state of special immune tolerance and are a susceptible population for this virus; there have been confirmed cases of pregnant women infected with the virus in China. The diagnosis and treatment of infected pregnant women should take into account the condition of both mother and fetus. Common clinical problems and management recommendations are summarized below:
Management of pregnant and postpartum women
1. Which medical institutions can treat pregnant women with fever or suspected infection?
Medical institutions with fever clinics, obstetrics departments, and neonatology departments, or designated medical institutions designated by health commissions at all levels.
2. Which pregnant women need to visit a fever clinic?
Pregnant women with fever or suspected cases will first undergo triage, have their temperature measured, and be guided by designated personnel to a designated fever clinic for treatment.
3. What are the criteria for determining a suspected case?
Having any one of the following epidemiological histories and meeting any two of the following clinical manifestations:
(1) Epidemiological history: ① Travel or residence history in Wuhan or other areas with ongoing local transmission within 14 days before the onset of illness; ② Contact with patients with fever or respiratory symptoms from Wuhan or other areas with ongoing local transmission within 14 days before the onset of illness; ③ Cluster of cases or epidemiological links with people infected with the novel coronavirus.
(2) Clinical manifestations: ① Fever; ② Chest CT imaging features: In the early stage, multiple small patchy shadows and interstitial changes are present, which are more obvious in the peripheral lung zone. It then develops into multiple ground-glass opacities and infiltrates in both lungs. In severe cases, pulmonary consolidation may occur. Pleural effusion is rare. ③ In the early stage of the disease, the total white blood cell count is normal or decreased, or the lymphocyte count is reduced. Pregnant women may not show typical blood cell count changes in the early stage of infection.
4. If a routine test for 8 respiratory viruses is positive, can COVID-19 infection be ruled out?
It cannot be ruled out. Based on existing clinical cases, patients with pneumonia caused by the novel coronavirus may also be infected with pathogens such as influenza A virus, influenza B virus, and Mycoplasma pneumoniae.
5. Can pregnant women have a chest CT scan?
Whether a radiological examination causes fetal developmental abnormalities depends on the gestational age and the radiation dose to the fetus from the radiological technique used. Theoretically, the radiation dose from a chest CT scan does not reach the teratogenic threshold and is relatively safe. However, for safety reasons, it is recommended that pregnant women undergo a chest CT scan after obtaining informed consent and take abdominal protection measures.
6. Can pregnant women take the antiviral drugs lopinavir/ritonavir?
This drug is listed as a first-line treatment option for HIV during pregnancy. Based on animal studies and limited human reports, this drug does not appear to increase the risk of adverse pregnancy outcomes. Healthcare professionals should fully inform pregnant women and their families about the benefits of using this drug and the potential risks to the fetus, weigh the risks and benefits, and choose to use the drug when the potential benefits outweigh the potential risks to the fetus.
7. Should prenatal checkups be routinely performed during an epidemic?
Pregnant women are a vulnerable group to the novel coronavirus. During the epidemic, routine prenatal checkups should be performed, and changes in fetal movement should be closely monitored. Women with pregnancy complications should appropriately increase the frequency of prenatal checkups.
8. What precautions should be taken when terminating a pregnancy during an epidemic?
A decision should be made based on a comprehensive analysis of the severity of the disease and the obstetric condition.
8.1 Indications for Termination of Pregnancy
(1) Obstetric indications: make judgments based on the specific obstetric situation and master the indications for termination of pregnancy.
(2) Severe cases: respiratory distress (RR≥30 breaths/min); or oxygen saturation ≤93% at rest; or arterial partial pressure of oxygen (PaO2)/oxygen concentration (FiO2) ≤300mmHg;
(3) Critically ill cases: respiratory failure requiring mechanical ventilation; or shock; or combined with other organ failure requiring ICU monitoring and treatment.
8.2 Timing and Method of Termination of Pregnancy
(1) For patients with mild symptoms and good cervical condition, vaginal delivery may be chosen;
(2) Indications for surgical termination of pregnancy: Same as 8.1.
8.3 Location for Termination of Pregnancy
A dedicated isolation room or operating room for respiratory infectious diseases in the fever ward.
8.4 Staffing
A multidisciplinary joint diagnosis and treatment team was formed, consisting of medical staff from obstetrics, neonatology, infectious diseases, respiratory medicine, anesthesiology, and operating room, and specialized surgical and anesthetic supplies were prepared.
9. What precautions should be taken when breastfeeding during an epidemic?
Breastfeeding is not recommended for suspected cases or confirmed cases that have not yet recovered.
Lopinavir/ritonavir is excreted in rat milk, but it is uncertain whether it is present in human breast milk. Therefore, breastfeeding is not recommended while taking this medication. Breastfeeding mothers should maintain good hand and breast hygiene.
10. What should be noted about postpartum fever?
Pregnant women experience physical exertion, blood loss, and significant fluid loss during childbirth, leading to internal environment imbalances and decreased immunity, making them a vulnerable group postpartum. Asymptomatic carriers may develop clinical symptoms during this period. If postpartum fever develops, after ruling out puerperal infections, breast engorgement, mastitis, and other obstetric conditions, the possibility of respiratory infections such as pneumonia, tuberculosis, or viral influenza should be considered. Currently, some cases have been found to present with fever within 6-48 hours postpartum, suspected to be COVID-19 infection. Therefore, in addition to routine respiratory virus screening, a chest CT scan is recommended. Suspected cases require further etiological examination for confirmation. Postpartum patients with fever after discharge should consult a fever clinic, and a gynecological consultation should be requested to rule out obstetric conditions.
Newborn Management
1. Can a pregnant woman who contracts the novel coronavirus transmit it to her fetus or newborn?
So far, no cases of neonatal infection have been found. However, it is still unclear whether the novel coronavirus is transmitted vertically through the placenta or through breastfeeding after birth. Therefore, for mothers diagnosed with novel coronavirus infection, newborns should be immediately isolated and observed for two weeks according to the virus infection procedure and should not be breastfed.
2. Which newborns need to be screened for novel coronavirus infection?
Possible routes of novel coronavirus infection in newborns include: mother-to-child vertical transmission, close contact transmission and droplet transmission (between family members, family visitors), and hospital-acquired infection. Therefore, individuals meeting any of the following criteria need to be screened:
①Pregnant women or postpartum women who are confirmed or highly suspected of being infected;
②Pregnant women who have been in close contact with family members who have been diagnosed with or are highly suspected of being infected;
③ There are confirmed or highly suspected cases among the family caregivers of the newborn.
3. How should newborn infants born to mothers who are confirmed or suspected of being infected be isolated?
After delivery, the newborn should be promptly assessed by a neonatologist. Newborns in good general condition should be taken home immediately for home isolation (see the second edition of the Tongji Hospital COVID-19 Prevention and Control Guidelines for specific isolation measures). Premature infants (<34 weeks) or infants with abnormalities after birth require hospitalization and should be isolated in the neonatal intensive care unit for necessary examinations and pathogen sampling, etiological analysis, and appropriate treatment.
4. What symptoms should prompt immediate medical attention if the newborn develops during home isolation after the mother has been diagnosed or is suspected of being infected?
The incubation period for the novel coronavirus in adults is 1-14 days, and it is recommended that newborns be isolated for at least 14 days. Clinical manifestations in newborns, especially premature infants, are nonspecific. If symptoms such as fever, cough, difficulty breathing, poor mental responsiveness, poor feeding, or repeated vomiting occur, medical attention should be sought immediately.
5. What precautions should be taken when a newborn is isolated at home if the mother is diagnosed with or suspected of being infected?
It is currently uncertain whether newborns can be infected or become a source of infection. During home isolation, the following preventative measures should be taken: single-room isolation, minimizing the number of caregivers, regular room ventilation, frequent handwashing by caregivers, and thorough disinfection of newborn items (using high temperature or 75% alcohol). Closely monitor the newborn's temperature, feeding, breathing, jaundice, etc., and seek medical attention if any discomfort arises.
6. Should newborns with no history of contact with confirmed cases be screened for novel coronavirus infection, and how should they be monitored?
If a newborn has no history of contact with infected individuals and shows no unusual discomfort, routine screening is unnecessary; normal newborn care should be followed. However, if any of the symptoms listed in section 4 appear, medical attention should be sought immediately.
The above content is exclusively authorized for use only and may not be reproduced without the copyright holder's authorization.
