Managing clinical deterioration in obstetric patients with a positive COVID-19 result

If the woman attends with a fever, investigate and treat as per guidance on sepsis in pregnancy Maternal Sepsis.

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. Antibiotic Policy for Obstetric Patients

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

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 > 40%, an increasing respiratory rate >30/min 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%.
• Have a low threshold to start antibiotics at presentation, with early review and rationalisation of antibiotics if COVID-19 is confirmed. 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 should have a VTE assessment and be prescribed prophylactic dose thromboprophylaxis, unless there is a suspicion of a VTE when therapeutic dose thromboprophylaxis should be administered.

For women with thrombocytopenia (platelets <50), stop aspirin prophylaxis and thromboprophylaxis and seek haematology advice.

Be aware of the interim government guidance based on the results of the RECOVERY trial, which states that steroid therapy should be considered for 10 days or to hospital discharge, whichever is sooner, for adults unwell with COVID-19 and requiring oxygen (in pregnant adults;

• oral prednisolone 40 mg once a day
• or intravenous hydrocortisone 80 mg twice a day.

Consider Remdesivir if SpO2 ≤ 94% on air or requiring supplemental O2 – this must be discussed with an Infectious Diseases physician and/or Intensivist.

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.

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 2-4 weeks after this taking into account gestation and other risk factors

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.