ASUHAN KEBIDANAN

Dosen Pengampuh : Elsa Noftalina, [Link]., [Link]

Disusun Oleh :
Ega Yuwita (19011149)

Kelas II A Kebidanan

Politeknik ‘Aisyiyah Pontianak

2020/2021
Ultrasound Obstet Gynecol 2020; 55: 586 – 592
Published online in Wiley Online Library ([Link]). DOI: 10.1002/uog.22014.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use
and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations
are made.

Coronavirus in pregnancy and delivery: rapid review

E. MULLINS1 , D. EVANS2,3, R. M. VINER3,4, P. O’BRIEN5,6 and E. MORRIS6,7
1
Department of Metabolism, Digestion and Reproduction, Imperial College London, Queen Charlotte’s and Chelsea Hospital, London,
UK; 2North Bristol NHS Trust, Bristol, UK; 3The Royal College of Paediatrics and Child Health, London, UK; 4University College
London, London, UK; 5University College London Hospitals NHS Foundation Trust, London, UK; 6The Royal College of Obstetricians
and Gynaecologists, London, UK; 7Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK

KEYWORDS: breastfeeding; COVID-19; fetal; miscarriage; neonatal; pregnancy; preterm birth

CONTRIBUTION (RCPCH) and RCOG who provided expert consensus on

What are the novel findings of this work? areas in which data were lacking.
This is the most up-to-date review of COVID-19 in Results From 9965 search results in PubMed and 600
pregnancy, with comparison to previous outbreaks of in MedRxiv, 21 relevant studies, all of which were case
novel coronavirus in pregnancy. We discuss the limited reports or case series, were identified. From reports of
data available, the limited evidence base for clinical 32 women to date affected by COVID-19 in pregnancy,
practice, possible therapeutic options in pregnancy and delivering 30 babies (one set of twins, three ongoing
future research. pregnancies), seven (22%) were asymptomatic and two
(6%) were admitted to the intensive care unit (ICU),
What are the clinical implications of this work? one of whom remained on extracorporeal membrane
A version of this rapid review, with searches up to 25 oxygenation. No maternal deaths have been reported
February 2020, informed the Royal College of Obste- to date. Delivery was by Cesarean section in 27 cases
tricians and Gynaecologists’ guidance on COVID-19 in and by vaginal delivery in two, and 15 (47%) delivered
pregnancy. preterm. There was one stillbirth and one neonatal
death. In 25 babies, no cases of vertical transmission
were reported; 15 were reported as being tested with
ABSTRACT
reverse transcription polymerase chain reaction after
Objectives There are limited case series reporting the delivery. Case fatality rates for SARS and MERS were
impact on women affected by coronavirus during 15% and 27%, respectively. SARS was associated with
pregnancy. In women affected by severe acute miscarriage or intrauterine death in five cases, and
respiratory syndrome (SARS) and Middle East fetal growth restriction was noted in two ongoing
respiratory syndrome (MERS), the case fatality rate pregnancies affected by SARS in the third trimester.
appears higher in those affected in pregnancy
Conclusions Serious morbidity occurred in 2/32 women
compared with non-pregnant women. We conducted a
with COVID-19, both of whom required ICU care.
rapid review to guide health policy and management of
Compared with SARS and MERS, COVID-19 appears
women affected by COVID-19 during pregnancy, which
less lethal, acknowledging the limited number of cases
was used to develop the Royal College of Obstetricians
reported to date and that one woman remains in
and Gynaecologists’ (RCOG) guidelines on COVID-19
a critical condition. Preterm delivery affected 47%
infection in pregnancy.
of women hospitalized with COVID-19, which may
Methods Searches were conducted in PubMed and put considerable pressure on neonatal services if the
MedRxiv to identify primary case reports, case series, UK’s reasonable worst-case scenario of 80% of the
observational studies and randomized controlled trials population being affected is realized. Based on this
describing women affected by coronavirus in review, RCOG, in consultation with RCPCH, developed
pregnancy. Data were extracted from relevant papers. guidance for delivery and neonatal care in pregnancies
This review has been used to develop guidelines with affected by COVID-19, which recommends that delivery
representatives of the Royal College of Paediatrics and
Child Health

Correspondence to: Dr E. Mullins, Department of Metabolism, Digestion and Reproduction, Imperial College London, Queen Charlotte’s
and Chelsea Hospital, DuCane Road London, London W12 0HS, UK (e-mail: [Link]@[Link])
Accepted: 13 March 2020

 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons REVIEW
Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
Rapid review: coronavirus in pregnancy 587

mode be determined primarily by obstetric indication RESULTS

and recommends against routine separation of affected
mothers and their babies. We hope that this review will The search of PubMed identified 9965 results; 69
be helpful for maternity and neonatal services planning abstracts were screened, of which 48 were excluded due
their response to COVID-19.  2020 The Authors. to the study not including pregnant women or humans,
Ultrasound in Obstetrics & Gynecology published by or being an in-vitro study. Twenty-one relevant studies
John Wiley & Sons Ltd on behalf of the International were identified2–22; their full texts were reviewed and all
Society of Ultrasound in Obstetrics and Gynecology. 21 were included. It is highly likely that there was overlap
in cases reported to be affected by SARS. The search
of MedRxiv identified 600 results; 39 abstracts were
screened and no relevant studies were identified.
INTRODUCTION All studies were case reports or series and all were
The common human coronaviruses 229E (alpha corona- classified subjectively as being of low quality. There was
virus), NL63 (alpha coronavirus), OC43 (beta corona- inconsistent reporting of maternal, perinatal and
virus) and HKU1 (beta coronavirus) cause the common neonatal outcomes. Outcomes of included cases are
cold. Three human coronaviruses cause more severe, summarized in Table 1. A narrative review is presented.
acute illnesses; MERS-CoV causes Middle East
respiratory syndrome (MERS), SARS-CoV causes severe Maternal outcome
acute respiratory syndrome (SARS) and SARS-CoV-2
causes COVID-19. COVID-19. To date, 32 women affected by COVID-19
There are limited case series reporting on the impact in pregnancy, including one with a twin pregnancy, have
of coronaviruses during pregnancy. In women affected been reported, delivering 30 infants (three pregnancies
by SARS or MERS, the case fatality rate appeared higher were ongoing) 2–5. Twenty-seven delivered by Cesarean
in those affected in pregnancy compared with non- and two by vaginal delivery. Women who delivered
pregnant women. did so within 13 days of onset of illness. In cases in
Person-to-person spread of COIVD-19 in the UK has which maternal morbidity and mortality were reported
now been confirmed. To guide treatment and prevention (n 23), two women required intensive care unit (ICU)
=
in women affected by COVID-19 during pregnancy in the admission and mechanical ventilation, one of whom
current outbreak, we conducted a rapid review. developed multiorgan dysfunction and was still on
extracorporeal membrane oxygenation (ECMO) when
the case was reported. When reported (n 17), all
=
METHODS symptomatic women had viral changes apparent on
computed tomographic (CT) chest imaging. There were
Searches were conducted in PubMed and MedRxiv on
no maternal deaths to date2,3.
25 February 2020 (Appendix S1) and updated on 10
SARS. The case fatality rate (CFR) was 15% for all
March to identify primary case reports, case series and
reported cases of SARS in pregnancy 6–11. A case– control
randomized controlled trials describing women of any
study comparing 10 pregnant and 40 non-pregnant
age affected by coronavirus in pregnancy or the postnatal
women affected by SARS in Hong Kong reported an ICU
period. There were no date or language restrictions on
admission rate of 60% and a CFR of 40% in the pregnant
the search. References of relevant papers were searched
group, compared with respective values of 17.5% and 0%
manually for relevant studies.
in the non-pregnant group 9. All women affected by SARS
Due to time constraints, one reviewer (E.M.)
had CT or chest X-ray evidence of pneumonia (Table 2).
conducted the search, reviewed full texts and extracted
MERS. In pregnant women affected by MERS, 7/11
data on demographics, maternal outcomes, maternal
(64%) were admitted to the ICU, and CFR was 3/11
diagnostic testing, maternal imaging, fetal, perinatal and
(27%)12–17.
neonatal outcomes, and neonatal diagnostic testing.
Comparison of outcomes between pregnancies affected
by COVID-19, SARS and MERS is presented. Early pregnancy
The review was not registered in PROSPERO and COVID-19. There are currently no data on first-trimester
corresponding authors were not contacted due to time COVID-19 infection.
constraints. The quality of included studies was assessed SARS. Miscarriage affected 4/7 women with first-
subjectively and classified as anecdotal, low, medium or trimester SARS infection8, all of whom had an
high. Ethical approval was not required for this review. ultrasound finding at 3 – 5 weeks of pregnancy of
This review has been used to develop interim unknown location or unknown viability, in which ongo-
guidance on COVID-19 infection in pregnancy, with ing pregnancy at 13 weeks would be expected in 38%
representatives of the Royal College of Paediatrics and 50%, respectively, acknowledging the complexity in
and Child Health (RCPCH) and the Royal College this area23,24. Those with fetal heart activity recorded
of Obstetricians and Gynaecologists (RCOG) providing (n 2) did not miscarry, neither did a woman in whom
expert consensus on areas in which data were lacking. =
the diagnosis was retrospective and did not undergo
This guidance has now been published in full by RCOG1. ultrasound examination.

 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ultrasound Obstet Gynecol 2020; 55: 586 – 592.
Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
588 Mullins et al.

Table 1 Overview of pregnancy and perinatal and neonatal outcomes in pregnancies affected by coronaviruses, according to gestational age
(GA) at diagnosis

COVID-19a SAR MERS

S
Second Third First Second Third First Second Third
Variable All trim trim All trim trim trim All trim trim trim

n 32b 2 30 20h 7 5 8 11 1 5 5
Maternal age (years) 30 (25 – 40) 31 (24 – 44) 33 (27 –
39)
GA at presentation 36.5 (25– 39) 16 (3 – 32) 24 (6 – 38)
(weeks)
Maternal comorbidity 4/19 (21)c NR 4/19 (21)c NR NR NR NR 5 (45) 0 (0) 2 (40) 3 (60)
Asymptomatic at 7 (22) 2 (100) 5 (17) 0 (0) 0 (0) 0 (0) 0 (0) 2 (18) 1 (100) 1 (20) 0 (0)
admission
ICU admission 2/23 (9)d 0 (0) 2/21 (10)d 6 (30) 1 (14) 2 (40) 3 (38) 7 (64) 0 (0) 3 (60) 4 (80)
Maternal mortality 0 (0)c,d 0 (0) 0 (0)c,d 3 (15) 1 (14) 1 (20) 1 (13) 3 (27) 0 (0) 1 (20) 2 (40)
Viral changes on chest 18/19 (95)c 20 (100) 8/9 (89)k
CT/X-ray in
symptomatic women
Miscarriage or IUD 1 (3)e 0 (0)e 1 (3)e 5 (25) 4 (57) 0 1 (13)j 2 (18) 0 (0) 1 (20) 1 (20)
Preterm delivery
Any 15 (47)f 0 (0)f 15 (50)f 4/13 (31)i NR 2 (40)i 2 (25)i 3 (27) 0 (0) 1 (20) 2 (40)
Spontaneous 0 (0) 0 (0) 0 (0)d 1 (5)i NR 0 (0)i 1 (13)i 0 (0) 0 (0) 0 (0) 0 (0)
Post-infection FGR NR NR NR 2 (10) NR 0 (0) 2 (25) 0 (0) 0 (0) 0 (0) 0 (0)
Vertical transmission 0/25 (0)g — 0/25 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Neonatal death 1/29 (3) — 1/29 (3) 0/13 (0) NR 0 (0) 0 (0) 1 (9) 0 (0) 1 (20) 0 (0)

Data are given as median (range), n (%) or n/N (%). aNo reported cases of first-trimester COVID-19 infection identified. bIncluding two
ongoing pregnancies diagnosed with COVID-19 in second trimester and one ongoing and one twin pregnancy diagnosed in third trimester,
giving total of 30 babies delivered. cIncomplete data from Liu et al.5. dIncomplete data from Zhu et al.4. eFetuses in ongoing pregnancies
were assumed to survive. fOngoing pregnancies were assumed to deliver at term, based on clinical prognosis. gNot all infants were tested
and some pregnancies were ongoing. hIncluding one twin pregnancy diagnosed with SARS in third trimester. iData (n 5) on timing of
=
delivery not reported by Zhang et al.19 but all were assumed to deliver at term. jOccurred in twin pregnancy. kOne woman declined
radiography because of concerns about effect on pregnancy and one woman was asymptomatic in first trimester. CT, computed tomo-
graphy; FGR, fetal growth restriction; ICU, intensive care unit; IUD, intrauterine death; MERS, Middle East respiratory syndrome; NR, not
reported; SARS, severe acute respiratory syndrome; trim, trimester.

MERS. A single case of a woman with MERS in

to have had an intrauterine death; this woman delivered
the first trimester has been reported. This woman was
vaginally and recovered after ICU admission without
asymptomatic and went on to have a term delivery18.
ventilatory support14.

Second/third-trimester pregnancy loss

COVID-19. One woman affected by COVID-19 pre- Prematurity
sented at 34 weeks with a fever and sore throat; her
condition deteriorated during admission and she COVID-19. Fifteen of the 32 (47%) women affected by
required COVID-19 delivered preterm. In the study of Chen et al.,
admission to the ICU and ECMO5. The woman had a
stillbirth, delivered by Cesarean section. No information all (n = 9) mothers were delivered electively by Cesarean
2
on chronology or fetal monitoring was reported. presented at 34 weeks with pre-eclampsia and MERS and
SARS. In cases of SARS reported after the first was found
trimester, Zhang et al. reported a series of five women
affected by SARS (two in the second trimester, three in
third trimester) in which there was loss of one fetus in a
twin pregnancy with the other surviving to delivery. It is
not clear if the loss occurred in the second or third
trimester; this has been recorded arbitrarily as occurring
in the third trimester19.
MERS. Two pregnancy losses were reported in
pregnancies affected by MERS. In the first case, the
woman became ill at 19 weeks gestation and experienced
vaginal bleeding resulting in late fetal loss at 20 weeks 17.
It should be noted that this woman declined chest
radiography and medication because of her concerns
about their effect on pregnancy. The second case
section, two of which were at 36 weeks’ gestation . In
the study of Zhu et al., seven women delivered by
Cesarean section and two by vaginal delivery 4; 5/9
women (6/10 babies) delivered preterm. The indication
for delivery is not reported; however, six babies were
affected by fetal distress prior to delivery and it seems
reasonable to assume that fetal condition contributed.
Wang et al. reported on one woman who delivered at
30 weeks for fetal distress 3. Liu et al. reported on 13
women, of whom seven delivered preterm by Cesarean
section; indication for delivery was not reported5.
SARS. Four of the 16 SARS pregnancies that were not
affected by miscarriage resulted in preterm delivery at
26, 28, 32 and 33 weeks’ gestation, respectively 18. Data
on timing of delivery were not reported in the series of
five women from Zhang et al.19.
Rapid review: coronavirus in pregnancy 589

Table 2 Details of women affected by coronavirus in pregnancy who died, as of 6 March 2020

Delivery and
Corona- MA GA Clinical neonatal Cause of
virus (years) (weeks) presentation Comorbidity Chest imaging Progression outcome maternal death
SARS8 44 5 Cough, NR Pneumonia Secondary Miscarriage Respiratory
headache, bacterial failure
SOB, chills pneumonia,
DIC, renal
failure, ARDS
34 32 Myalgia, NR Pneumonia Sepsis, ARDS, CS, neonatal Respiratory
cough, shock, survival failure
chills abdominal
wound
dehiscence
34 27 Myalgia, NR Pneumonia Secondary CS, ARDS, MRSA
cough, bacterial NEC, pneumonia
headache, pneumonia, neonatal
SOB, sore DIC, ARDS, survival
throat abdominal
wound
dehiscence
MERS20 32 38 Fever, cough, None Bilateral Worsening Spontaneous Multiorgan
SOB infiltrates pneumonia, vaginal failure
(chest renal failure, delivery,
X-ray) ARDS neonatal
survival
31 24 Cough, Asthma, Right lower Worsening Emergency CS Severe
refractory
myalgia pulmonary lobe opacity pneumonia, for maternal hypoxia,
fibrosis, ARDS hypoxemia, cardiac arrest
spontaneous neonatal
pneumotho- death
races
32 32 Fever, back None Bilateral con- Septic shock Emergency CS Septic shock
pain solidation for maternal
(CT) hypoxemia,
neonatal
death

There were no maternal deaths in COVID-19 cases. ARDS, acute respiratory distress syndrome; CS, Cesarean section; CT, computed
tomography; DIC, disseminated intravascular coagulation; GA, gestational age; MA, maternal age; MERS, Middle East respiratory
syndrome; MRSA, methicillin-resistant Staphylococcus aureus; NEC, necrotizing enterocolitis; NR, not reported; SARS, severe acute
respiratory syndrome; SOB, shortness of breath.

MERS. Three of the 11 pregnancies with MERS were

MERS. Four of the 11 women with MERS went
delivered preterm by Cesarean section (one at 24
on to deliver a healthy baby at term, although birth
weeks and two at 32 weeks for maternal
weight was not reported in 3/4 of these cases. In one
hypoxemia)12,18.
case, vaginal bleeding was reported at 37 weeks,
causing fetal compromise and necessitating emergency
Fetal growth and placental effects
Cesarean section resulting in the delivery of a male
COVID-19. Women affected by COVID-19 who deliv- infant weighing 3140 g and in good condition.
ered did so within 13 days of onset of illness2–5; fetal Abruption was apparent on placental examination13.
growth is unlikely to be affected in this time period.
There were no data on fetal growth in the three ongo-
ing pregnancies at the time of publication 5. No placental Delivery and postnatal
pathology is available to date. COVID-19. Chen et al. reported on nine women with
SARS. Placentas from pregnancies affected by SARS COVID-19 delivering by Cesarean section from 36 weeks
showed early changes (fibrin deposition), that are seen in onwards, of which two were preterm. In two women
pregnancies with fetal growth restriction, when delivery at term, fetal distress was reported. In six women
occurred 1 week after onset of illness; birth weight with COVID-19 who delivered by Cesarean section and
≤
was normal in these pregnancies 20. When delivery was subsequently underwent testing, there was no evidence
5– 7 weeks after onset of illness, there was fetal growth of COVID-19 in the amniotic fluid, umbilical cord blood,
restriction in 2/3 pregnancies8 and their placentas neonatal throat swab or breast milk samples 2. A news
showed more severe changes (areas with loss of blood report of a baby of a COVID-19-infected mother testing
supply, avascular villi, bleeding behind the placenta, positive at 30 h after delivery has not been reported in a
placental abruption)20.
590 Mullins et al.

scientific journal. Zhu et al. reported COVID-19 in nine

DISCUSSION
women delivering 10 infants (seven by Cesarean section
and two by vaginal delivery), of whom only three There are limited data on the impact of the current
mothers became symptomatic after delivery. The COVID-19 outbreak on women affected in pregnancy and
indication for delivery was not reported. This cohort had their babies. All studies included in this review were case
COVID-19 from 31 weeks onwards, 6/9 pregnancies reports or series of low quality. Reported outcomes
showed fetal distress and 5/9 women (6/10 babies) varied, with one series on COVID-19 not reporting
delivered preterm4. Wang et al. reported on one woman maternal outcome.
who underwent Cesarean section for fetal distress at 30 Of the 23/32 women with COVID-19 in pregnancy
weeks’ gestation. The infant was born in good condition for whom maternal outcomes were reported, two had
and samples of amniotic fluid, neonatal gastric samples, serious morbidity, one of whom was still on ECMO
placenta and infant throat swabs were negative for following stillbirth, at the time her care was reported.
COVID-193. Liu et al. reported on 10 women, all of Compared with SARS and MERS, COVID-19 appears to
whom delivered by Cesarean section. Vertical be less lethal, although acknowledging the limited
transmission was reported as negative in all 10 neonates. number of cases reported to date and that one woman
The samples and method of testing is not stated5. remains in a critical condition. Preterm delivery
SARS and MERS. No vertical transmission was affected 47% of women hospitalized with COVID-19,
reported for cases of SARS or MERS in pregnancies which may put considerable pressure on neonatal
delivered by Cesarean section or vaginal delivery. services if the UK’s reasonable worst-case scenario of
Other coronaviruses. A single case series reported 80% of the population being affected is realized.
on neonates born to mothers who were positive for RCOG, in consultation with the RCPCH, have pro-
HCoV-229E; gastric samples in three out of seven cases vided guidance for delivery and neonatal care, which rec-
were positive for HCoV-229E on reverse transcription ommends that delivery mode be determined primarily by
polymerase chain reaction (RT-PCR); seroconversion obstetric indication, and recommends against routine
was not assessed. No signs of infant infection were seen sep- aration of COVID-19-affected mothers and their
in those with positive gastric samples21. babies1. From the currently available data, an increase in
the risk of miscarriage in women affected by COVID-19
Neonatal outcome cannot be ruled out at this stage, given the SARS data.
Data from early pregnancy units are needed on affected
COVID-19. In the study of Chen et al., all (n 9) babies women and
=
were delivered 36 weeks’ gestation and were well at matched controls.
2 ≥
discharge . Zhu et al. reported on a cohort delivered at In women affected by COVID-19 with ongoing
an earlier gestational age (from 31 weeks); 6/10 babies pregnancy, surveillance for fetal growth restriction would
were admitted to the neonatal unit for respiratory be reasonable, given the acute and chronic placental
support, two developed disseminated intravascular changes observed in SARS pregnancies and with 2/3
coagulation (DIC) and one had multiple organ failure 4. of those that were ongoing being affected by fetal
Neonatal morbidity was more marked in this series, growth restriction after SARS infection, and that
probably due to greater prematurity. One baby died after placental abruption was noted in a case affected by
being born at 34 weeks. The neonate required admission MERS.
at 30 min after delivery with respiratory difficulties. The The need for provision of fetal monitoring, including
baby’s condition deteriorated, and it developed shock, serial ultrasound examination, of women with COVID-19
DIC and multiple organ failure, and died at 8 days will be challenging for maternity services. Women
postpartum. Nine of the 10 infants were tested for will need to be monitored locally in their booking
COVID-19, all of which tested negative. Wang et al. maternity units, with transfer to centers with
reported on a baby born at 30 weeks in good condition appropriate neonatal intensive care facilities for delivery.
with an uneventful neonatal course 3. Liu et al. reported COVID-19 is associated with preterm delivery in 47% of
on one stillborn and nine liveborn neonates, all of which reported cases. In SARS and MERS-affected cases,
had an Apgar score (time unspecified) of 105. delivery was most often indicated by maternal
SARS. Among pregnancies affected by SARS, a baby hypoxemia. In COVID-19, if maternal illness is not as
born at 26 weeks had respiratory distress syndrome severe, the considerations will be
(RDS) and a bowel perforation. In another case, a baby based more on obstetric indications for delivery.
born at 28 weeks had RDS, necrotizing enterocolitis and Information on vertical transmission of COVID-19
a patent ductus arteriosus8,11. is limited, although testing of 15 neonates born to
MERS. Among the three MERS pregnancies that were mothers with COVID-19 was negative in all cases.
not affected by stillbirth or intrauterine death and that Guidance on mode of delivery requires expert consensus
were delivered preterm by Cesarean section, one until further information emerges. RCOG advises that
delivered at 24 weeks and resulted in neonatal death decisions regarding mode of delivery should be on
(birth weight, 240 g) and the other two delivered at 32 obstetric indication and not on presumed protection of
weeks for maternal hypoxemia and have no outcomes the baby against infection. There is evidence for vertical
reported12,20. transmission of HCoV-229E; however, seroconversion
was not investigated and all infants remained well 21.
There is no evidence for vertical transmission for any
other coronavirus.
Rapid review: coronavirus in pregnancy 591
seem reasonable not to exclude seriously ill pregnant
women from trials of these therapies for COVID-19.
We acknowledge the limitations of this review, given
that a full and comprehensive search of all medical
literature would have taken more time and personnel
than were available. We used a single reviewer and a
limited database search in order to conduct this rapid
review.
There is discrepancy between guidance for delayed
cord clamping, which is a function of a lack of
evidence. Consensus guidance from China advises
that ‘delayed cord clamping is not recommended’, in
order to reduce the risk of vertical transmission, and
that infants should be separated from mothers affected
by COVID-1925. Interim guidance from ISUOG advises
clinicians to consider not undertaking delayed cord
clamping26. RCOG guidance does not concur, advising
that delayed cord clamping should be practiced as
normal. If vaginal delivery is permitted, with
exposure to maternal secretions and blood, it could
be argued that 1 min of further perfusion via the
placenta is unlikely to alter the risk of vertical
transmission. Infants may acquire COVID-19 from
their mothers after delivery via normal routes of
transmission. Guidance from China states that ‘Infants
should not be fed with the breast milk from mothers
with confirmed or suspected 2019-nCoV’. Guidance
from the Centers for Disease Control and Prevention
is less clear but is still precautionary27. RCOG advises
against routine separation of mother and baby and
gives guidance on
individualized care.
If the UK’s reasonable worst-case scenario of 80% of
the population being affected by COVID-19 is realized
and 4% require hospitalization, thousands of pregnant
women will potentially be affected at a time at which
staff are likely themselves to be unwell. In previous
coronavirus epidemics, there has anecdotally been a
tendency towards admitting any symptomatic pregnant
woman with proven infection.
A surge in workload will likely be seen in healthcare
services across the world at a time at which staffing is
well below optimal levels. Pragmatic choices will need to
be made about achievable and acceptable levels of care
according to national guidance and local adaptation.
Chest imaging should be undertaken in pregnant women
as clinically indicated.
Therapeutics announced as being under consideration
and trial during the outbreak include Kaletra (lopinavir
and ritonavir), remdesivir and chloroquine. Kaletra 28 is
used in the UK during pregnancy for treatment of HIV,
in which the benefits of treatment outweigh the risks
of toxicity seen in animal studies. The benefits of using
chloroquine outweigh the risks in the prevention and
treatment of malaria during pregnancy 29. Remdesivir
has been used for the treatment of Ebola in pregnant
women30. However, it should be acknowledged that
Ebola is a condition with a CFR of 50%, and for which
there would be higher tolerance for adverse effects of a
potentially beneficial treatment than would be the case
for COVID-19, in which the CFR is around 1%. It would
 There is a need for systematic data reporting on
women affected by COVID-19 and their pregnancies to
provide an evidence base for management, treatment
and prevention, and to target limited resources during
the outbreak.

DISCLOSURE

E.M. is seconded to the Department of Health and

Social Care (DHSC), England. The views in this
manuscript are those of the authors and do not
necessarily represent the official views of DHSC or HM
Government. E.M. has applied for a UKRI/MRC grant
to study COVID-19 in pregnancy. No other authors
have conflicts of interest to declare. E.M. received a
salary from the NIHR.

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