exempting pregnant nurses from providing direct care to COVID-19 patients and suggesting quarantining during the last two weeks of pregnancy to avoid infection in labor . In part due to the rapidly growing shortage of health care workers , institutional policies never really adjusted to this . Fortunately , for the majority of our pregnant patients , the on and off closings and substantial shift to working from home helped reduce risk , although our patients are generally a younger demographic , often employed in public facing jobs that are not amenable to working from home .
During the first two waves , most of our rare experiences with COVID-19 positive patients came from admission screening that was implemented for all laboring patients . The majority were asymptomatic but caused a great deal of stress for the personnel working with them . New protocols were rapidly implemented and frequently revised . In that early phase , different sections of triage were “ hot zones ,” only used on suspected COVID-19 cases , constraining resources . During initial PPE shortages , it took weeks of discussion to be allowed to use an N-95 mask when pushing with a COVID-19 positive patient at delivery ( heavy exertion at a distance of three feet ). Deliveries are usually a joyful and exciting experience , despite the best PPE , there are a lot of fluids and air that get shared in a delivery room . Protocols for staffing deliveries and especially cesarean deliveries had to be worked out .
Early protocols also caused stress to our patients with and without COVID-19 . Limited visitation is hard in an ICU , but also very disappointing in a delivery room . For several days at the peak of the first wave , even partners and spouses were not allowed to be present . That was reversed , but for a long time only one visitor was allowed with our patients . In COVID-19 positive mothers , we initially struggled with how to manage care of the infant . Options were to isolate the baby from the mother , or require them to room in , wear a mask and keep the baby six feet from the mother . We didn ’ t know if breast feeding was okay , to be encouraged , or dangerous . Circumcision for male babies with COVID-19 positive mothers could not be accommodated , as they were not allowed in the nursery .
There are a number of unique interactions between obstetrical care and COVID-19 . Obstetrics is very hands on . Visits are frequent , and most must be in person . We did stretch out some of the routine visits , but still need a minimum of six to eight visits even in lowrisk pregnancies . Most of obstetrics is not elective . Care can only be slightly delayed during a pandemic . Births are going to happen at the same rate despite staffing issues . While we rescheduled a lot of gynecological visits during the first peak , we remained open for our obstetrical population . We probably never exceeded 10 % of our visits as appropriate for telehealth visits . For actively infected patients managed as outpatients , appointments can usually be scheduled around the typical two-week quarantine period . In high-risk or late gestation pregnancies , that is not possible . We developed a system to call the patient in from her car , bring her in a back door and use designated rooms with enhanced cleaning and prolonged turnover time between patients .
TWO PATIENTS IN ONE
Pregnancy alters a number of physiologic parameters that impact management of COVID-19 infection . Normal obstetrical symptoms of nausea , shortness of air , relative tachycardia and fatigue can make early diagnosis of COVID-19 more difficult . The requirement for adequate fetal oxygenation means that rather than initiating hospitalization or more intensive therapy at O2 sat levels of 80 %, we have to be concerned at 94 %. In a number of situations where maternal cardiopulmonary function is compromised , early delivery can lead to improvement . In COVID-19 , this has led to an increased risk of cesarean section if our patients had enough deterioration to require intubation after fetal viability has been reached .
Pregnancy is a risk factor for hypercoagulability , as is COVID-19 . Lovenox prophylaxis is important in hospitalized cases , and we routinely recommend low dose aspirin in those still pregnant after infection . Labs frequently used to monitor progression of disease such as C reactive protein or D-dimer are more difficult to interpret , as they are elevated in normal pregnancy . Other lab impacts of COVID-19 can cause confusion in the diagnosis of common pregnancy complications . Elevated levels of ALT , AST and low platelets occur with COVID-19 as well as pre-eclampsia , HELLP syndrome and cholestasis of pregnancy .
Medications to treat COVID-19 have evolved with experience , and in pregnancy we must consider possible adverse effects on the fetus . Outpatient management of mild disease is mostly over the counter symptomatic medications , which are fine in pregnancy . O2 sat monitoring is important due to confusion between low oxygen levels and normal pregnancy symptoms . Since pregnancy is a risk factor for severe disease , we have been using Regeneron ( casirivimab-imdevimab ) for asymptomatic disease when available , although it is less effective with the recent Omicron variant . Sotrovimab is probably more effective , but neither is currently available with the recent dramatic rise in cases .
Most medications commonly used during hospitalization , including Remdesivir , dexamethasone , Vit C , ritonavir and azithromycin are probably safe in pregnancy . Molnupiravir and baricitinib may have fetal toxicity particularly in early pregnancy , while tocilizumab and sarilumab might cause suppression of fetal immune response . A general principal of severe illness in pregnancy however , especially prior to fetal viability , is that maternal survival is paramount . Given the frequent lack of good data on medications during pregnancy , shared decision making is important , balancing concerns of harm from a medication versus risk from the untreated disease .
In many infectious diseases ( Zika , CMV , rubella , varicella , syphilis ) vertical transmission is a significant concern . This does not appear to be the case in COVID-19 , with a probable vertical transmission rate of ~ 1 %. Although the virus does not cross the placenta , IgG antibodies do , resulting in newborns having passive immunity to COVID-19 , lasting three to four months .
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