COVID-19 in Pregnancy

COVID-19 in pregnancy is infection with SARS-CoV-2, causing illness from mild upper respiratory symptoms to severe pneumonia. Pregnancy increases the risk of severe disease, intensive care admission, preterm birth and stillbirth. Vaccination lowers the risk, and most women recover with supportive care.

• Risk factors: obesity, diabetes, hypertension, age above 35 years, HIV, third trimester, unvaccinated state.
• Severe disease is more likely in the third trimester.
• Vaccination in any trimester is safe.

Women have fever, cough, sore throat, loss of smell or taste, headache, myalgia and diarrhoea, and in severe disease breathlessness and low oxygen saturation. Check respiratory rate and saturation at rest and after walking.

• Silent hypoxia is possible.
• Symptoms start 2 to 14 days after exposure.
• Differential diagnosis: influenza, malaria, pneumonia, pulmonary embolism, peripartum cardiomyopathy, preeclampsia (hypertension and proteinuria), dengue.
• Complications: pneumonia, respiratory failure, venous thromboembolism, preterm birth, stillbirth, preeclampsia, maternal death.

The diagnosis is by laboratory or rapid antigen testing with assessment of severity.

• SARS-CoV-2 antigen or PCR on nasal or throat swab.
• Oxygen saturation (severe below 94 percent), respiratory rate (severe 30 per minute or above).
• Full blood count, urea, creatinine, liver enzymes, D-dimer interpreted with caution, C-reactive protein; chest X-ray with shielding for suspected pneumonia.
• Malaria test in endemic areas to exclude co-infection.

The principle is supportive care with oxygen, steroids for hypoxic disease and clot prevention.

• Supportive: isolation at home for mild disease; fluids; rest; left lateral position; monitor saturation 3 times daily with a pulse oximeter; oxygen to keep saturation at 95 percent or above; prone positioning while awake, including a left or right side lying position in late pregnancy; fetal movement counts.
• Pharmacological: paracetamol 1 g oral 6-hourly as needed (maximum 4 g in 24 hours); dexamethasone 6 mg oral or IV once daily for up to 10 days for women needing oxygen; enoxaparin 40 mg subcutaneous daily during admission and for 10 days after discharge (weight 50 to 90 kg; 60 mg if above 90 kg); antibiotics only for suspected bacterial infection: amoxicillin 1 g oral 8-hourly for 5 days; betamethasone 12 mg IM twice, 24 hours apart, only if delivery before 34 weeks is planned.
• Procedures: intubation for respiratory failure; delivery is decided on obstetric reasons or maternal deterioration.
• Special groups: women with severe disease and gestation above 28 weeks may need delivery to ease ventilation; breastfeeding continues with a mask and hand washing.
• Red flags: oxygen saturation below 94 percent, respiratory rate above 30 per minute, chest pain, confusion, haemoptysis, leg swelling, reduced fetal movements.
• Follow-up: review at 7 and 14 days; growth scan 2 to 4 weeks after recovery from moderate or severe disease; postnatal enoxaparin for 6 weeks if risk factors persist.