Dr Danie Schneider
Obstetrician and Gynaecologist, Somerset West

Corona virus and pregnancy

Corona virus and pregnancy

The information below is provided as a service to the patients of the practice of Dr Danie Schneider and is not intended as an academic review. Please note that this is a practical guide directed at the pregnant patients of our practice. This is a personal opinion of the research applicable to the practical issues my patients and I could be faced with during this pandemic. New evidence becomes available on a regular basis and you might find that we do things differently on the day when you present to Mediclinic Stellenbosch.

 

Who is at risk of  Covid-19/how do  know if I am at risk?

The first cases in South Africa were in travellers from Europe. This phase is called the initiation phase, but community spread is now occurring and the disease will accelerate. We are now seeing cases among close contacts of a known case, but also cases where the source is unknown. It is prudent to change your approach now to recognising possible sources of infection around you in your community. Everyone is regarded as at risk now and we should therefore practise preventative measures.

 

What are general preventive measures to follow in pregnancy?

Hand wash regularly and frequently with soap and water or an alcohol based hand rub.

Avoid anyone who is coughing or sneezing.

Avoid touching your eyes, nose or mouth.

Practise social distancing and reduce general community exposure

Report symptoms early.

We will have a low threshold to start appropriate treatment and supportive measures if there is significant infection.

Remember the flu immunisation!

 

How will I be tested for COVID- 19?

You will be tested the same as anyone else being tested. We do not change the way we test for Corona because you are pregnant. Swabs are taken from your mouth and nose. We occasionally will test sputum or saliva. At present our local Pathcare testing facility is at Vergelegen Mediclinic Pathcare drive -through lab. Remember that testing should only be done in symptomatic patients. Note that Pathcare request that the account is settled immediately.

 

Should an X-ray or lung scan be done in a pregnant women with COVID-19 infection?

A chest CT scan is often essential for the evaluation of the clinical condition of a pregnant woman with COVID-19 infection. According to research from the American College of Radiology and The American College of Obstetricians and Gynecologists, when a pregnant woman undergoes a single chest X-ray examination, the radiation dose to the fetus is 0.0005–0.01mGy, which is negligible. The radiation dose to the fetus from a single chest CT is only 0.01–0.66mGy.   A radiation shield will be applied over the uterus during the procedure.

Why should I get a flu immunisation this year?

Please see the separate entry on immunisations in pregnancy, where influenza immunisation and whooping cough immunisation are discussed.  Both immunisations are still advised in pregnancy.

It is strongly advised that you get a flu immunisation during any stage of pregnancy in 2020. While it will not influence your body’s response to COVID-19 infection, you will reduce your risk of influenza through vaccination. You therefore lower your risk of needing treatment or assessment for symptoms of viral infection (that would cause confusion during the COVID 19 outbreak) and put less stress on a potentially overburdened health system in 2020. There is also new evidence that shows protection of the baby against flu after birth, if the mother was immunised during pregnancy.

We advise you to get the Vaxigrip Tetra as it is a four-strain Influenza vaccine.

 

What treatment is available for corona virus?

Unfortunately no vaccination is currently available for COVID-19.

Most pregnant women will get a mild infection and treatment is symptomatic. You will most likely be able to rest at home and take oral paracetamol for fever and muscle aches. Drink plenty of fluids. You will be required to self-isolate and avoid contact with others.

Hospitalised patients will normally receive supportive therapy especially if the lungs are affected. The oxygen saturation level in your blood will be closely monitored. If there is a suspicion of a co-infection, then appropriate antibiotics or treatment for influenza will be started.

At present we do not have a drug available that has been tested well enough against COVID-19, but  various treatments are being used and a breakthrough is expected soon. An anti-malarial drug is showing promise.

We will also monitor your baby’s heart rate closely during hospitalisation and continue to monitor the baby’s growth by regular ultrasound examinations.

 

Are pregnant women at risk?

The physiological changes of pregnancy predispose women to respiratory complications of viral infection. Pregnant women are therefore more prone to develop severe illness after infection with respiratory viruses. With every flu epidemic a small percentage of pregnant women develop severe lung problems. This is particularly true towards the end of the pregnancy.

The good news is that there is no evidence that pregnant women are more susceptible to COVID- 19 infection. You are therefore no more likely to contract the infection than the general population. We also do not have evidence that pregnant women with COVID -19 infections are more prone to developing lung infection than the general population.

There have not been any reported deaths of pregnant women from coronavirus. Most women experience very mild or moderate flu-like symptoms and it is expected that you will make a full recovery.

 

Are certain pregnant women more at risk of severe disease than others?

This is a new virus and we do not have sufficient scientific data available to comment. The general feeling is that women with HIV (especially if immunosuppressed) and possibly those with severe asthma and diabetes could be more unwell if they develop coronavirus infection in pregnancy.  As with other viral infections in pregnancy e.g. swine flu, some women develop a more severe disease after 28 weeks, than in early pregnancy.

 

Is my baby at risk?

There is at present no information available suggesting an increased risk of miscarriage with COVID -19 infection in pregnancy. There is also no evidence of vertical transmission (meaning no risk that the virus can be passed on to your baby while you are pregnant). We do not believe that there is a risk of abnormalities to your baby and your baby’s development should be normal.

During the outbreak in China there was a higher incidence of premature delivery amongst women who were symptomatic for COVID 19. At present we are not sure if this was due to a decision made by the attending doctors to deliver the babies earlier or any other reason.

 

Can the virus be transmitted to my baby during normal birth?

Remember that we have no evidence of women diagnosed with coronavirus during the third trimester of pregnancy having passed the virus to their babies. The current evidence also suggests that the virus is not present in genital fluid. The evidence is based on small numbers, but is reassuring.

 

Can the virus be transmitted to my baby after birth?

There is no evidence at present of the virus being transmitted to the baby in a mother who tested positive for corona virus in the third trimester. The reports from China that showed that a minority of babies contracted the virus after birth have all been attributed to the close contact with an infected mother or staff member on the ward. See the reference to breast feeding below.

If you have suspected or confirmed corona virus at the time of your birth, your baby will be tested for corona virus.

You should be careful to avoid passing the virus to your baby after birth. This is best done by washing your hands before touching the baby, avoid touching the baby’s face and avoid coughing or sneezing on the baby. It can be helpful to wear a mask if this is available. It will be helpful when not caring for your baby (e.g. baby is sleeping) , to remain at least 2 meters from the baby.

After birth it is important to continue limiting visitors and   practice social distancing.

 

Can I breastfeed if I have COVID-19?

At the moment there is no evidence that the virus can be carried in breast milk. It is generally felt that  the well-known benefits of breastfeeding outweigh any potential risk of transmission of corona virus through breast milk.

It therefore appears safe to breastfeed your baby even if you have COVID-19. The main risk of breastfeeding is close contact between you and your baby. You should therefore be careful to avoid passing on the virus to your baby. Provide your baby is well and don’t require care in the neonatal unit, you will be kept together with your baby. The normal precautions as discussed above apply.

Another option to consider is to pump or express the breast milk and have someone who is not sick with COVID-19 feed the milk to your baby. Be sure to wash your hands well before collecting the breast milk.

 

If I recently had COVID-19 infection, what are the implications for my baby after birth?

If you already had COVID-19, recent research seems to indicate that your body will be able to fight the virus without you becoming sick again. But even in this case, washing your hands before touching your baby is the best way to prevent carrying the virus to your baby from a sick person or an object they touched.

 

How would labour be managed if I have Covid19?

Your planned method of birth and your birth plan would unlikely need to change if you are infected with corona virus. Please be aware that the healthcare workers present at your birth will have to wear protective clothing. There is however currently no evidence that you cannot give birth vaginally or that it is safer to do a caesarean section. A caesarean section will however be advised in women who have severe respiratory symptoms. We will discuss this early in labour.

Your birth partner will still be allowed during labour, but visitors will not. Please note that birth partners who are symptomatic for corona virus infection cannot be allowed to attend with you. Have a plan B in place to cover this scenario.

An epidural or spinal analgesia is not contra indicated and we would in fact advise the early placement of an epidural if you are positive for COVID-19 and plan a vaginal delivery. This will minimise the need for a general anaesthetic if urgent delivery is indicated later. A general anaesthetic is a high risk procedure for the theatre team and a lot of time is spent on preparations to minimise exposure of the medical team and this could delay the urgent birth of your baby.

We advise continuous fetal monitoring by CTG during labour if you are COVID-19 positive. Your oxygen saturation level will also be monitored. There is a slightly higher chance that we will advise a ventouse delivery to assist with the birth to prevent you from becoming tired from pushing too long.

Delayed cord clamping can be done as is usual practice.

 

Will a caesarean section be done in the usual fashion?

Regional anaesthesia (spinal or epidural) is advised.  Standard obstetric theatre principles will apply as before. If you however need a general anaesthetic for delivery, then the risk of transmission of corona virus to the attending staff increases dramatically. All staff in the theatre will then need to wear special protective clothing.

 

When should I self-isolate?

You will be asked to self-isolate if you test positive for corona virus and have been asked to recover at home.  You may be advised to self-isolate if you have a high temperature or a new, continuous cough.

 

What should I do if I have to self-isolate in pregnancy?

 You should inform the practice if you are asked to self-isolate. We will review your antenatal records and then give you guidance. We will ask you to phone every few days to tell us that all is well. We will reschedule your antenatal appointments and try to delay these visits until the isolation ends. Tests that you miss can usually be done on follow up. If you miss your Strep B test at 37 weeks we will treat you as Strep B positive if applicable.

We will warn Mediclinic Stellenbosch labour ward (ward D) that a pregnant patient is in self-isolation so that the necessary preparations are in place if you need to come to hospital during this phase. You should contact labour ward or the practice if you have concerns about your own well being or your baby. You will then be told how and where you should present to the ward for assessment.

We will usually arrange a follow up after the 14 day period and a growth scan will be done.

 

What if I go into labour during self-isolation?

Phone  Mediclinic Stellenbosch Ward D before coming in to hospital. Explain that you are in self-isolation and follow their advice on how you should attend. Phone Dr Schneider if any uncertainty, but the ward would let me know when you arrive.

 

Should I continue to work during the pandemic?

As a general measure we are all advised to follow guidance on social distancing measures to reduce social interaction between people in order to lessen the transmission of corona virus.

It is generally believed that pregnant women under 28 weeks should follow the guidance on social distancing in the same way as the general public and that you may continue to work as normal. Social distancing measures should be in place at work. Note that the OHSA states that an Employer must ensure that its working environment is safe and without risk to the health of its Employees. It is recommended that these measures should include as little as possible physical contact with others.

Remember that you need to produce a medical certificate as per BCEA rules if you are sick. If you do contract the corona virus and you have not exhausted your sick leave benefits as per BCEA, then you are entitled to receive full benefits.

It is generally felt that pregnant women after 28 weeks and those pregnant women with heart and lung problems may experience more severe symptoms from the virus.  A more precautionary approach is therefore advised and it is ideal if you could work from home or change the work environment to follow social distancing advice. Discuss this with your employer.

During lockdown you should follow the published guidelines applicable to your work.

 

Should I continue with ante natal follow up?

We aim to continue to provide a high quality obstetric service in the setting of the corona virus pandemic. Regular scheduled ante natal visits are essential in lowering your risk of pregnancy related problems. Our aim is for you and your baby to stay healthy. To achieve this we need to see you for scheduled appointments.

A number of important measures have been put in play to lower your risk of corona virus exposure while at the same time prevent exposure to health care providers:

Be aware that we have to stay flexible going forward and that appointments could be changed at short notice. Please familiarise yourself with the latest indications for self-isolation and testing for Covid19. Phone Sr Patricia before your visit if you have any uncertainties about whether you should keep your appointment. Be aware that you will be required to fill in a short questionnaire as part of pre-screening when arriving at Mediclinic Stellenbosch. Be assured that all staff will also be screened daily.

Please do not travel by public transport to the practice.

If you have to bring others along to the hospital, we kindly request that they wait for you outside the hospital. Do not wander around in the hospital on your way to and from our room.

Use the hand sanitisers freely available throughout the hospital premises as well as in the practice.

We clean surfaces and instruments continuously, but rely on you to pay attention to your personal hygiene. Wash hands frequently.  Don’t touch your face. Cover coughs and sneezes.

Practise social distancing on the way to the practice and after leaving the practice.

We will adjust the appointments to ensure that as far as possible you are the only person in the waiting area.

Please be on time and understand that if we adjust your appointment time it is for your own best interest.

Contact Elsa and arrange internet payment if this will give you more reassurance rather than payment by card or with cash.

 

Is Mediclinic Stellenbosch labour ward a safe place to deliver during the pandemic?

The labour ward is isolated from the rest of the hospital and this design works in our favour with the recent outbreak. All pregnant patients are known to their individual doctors for at least 9 months. The routine antenatal consultations give us time to assess risk, arrange appropriate tests and introduce preventative treatment. This is different to the other departments in a hospital and we can hopefully use this to our advantage during the outbreak to lower the risk of exposure to corona virus.

All the rooms in ward D are single, private rooms and the access to the ward is controlled by a security door. This again works in our favour with the corona virus outbreak. It would be possible to keep infected patients isolated from the rest. We have also put restrictions in place for visitors as well as non-essential services.

 

What if I feel depressed or anxious about corona virus?

Being pregnant can be a worrying time for many women even if all is well. Sometimes a small percentage of women become depressed. We have years of experience and research on helping pregnant women cope with all sorts of problems in pregnancy. Often all that is needed to help with the feeling of hopelessness is to talk to a professional. Sometimes we need to use medication and we have lots of research to guide us with the decision about what is safe medication to use.

It is important to inform us if any other practitioner puts you on any medication to enhance your mood during pregnancy.

Phone the practice and discuss your feelings with us. We will arrange follow up as indicated.

The practical problem with corona virus is that face to face consultations with psychologists or psychiatrists pose risks. Alternative methods of assessment can be arranged if needed.

Help is at hand, just talk to us!

 

Any special advice during lockdown?

Remember to stay active and following the healthy eating guidelines for pregnancy. See separate posts on exercise in pregnancy as well as diet and weight gain in pregnancy. 

It is prudent to continue practising social distancing measures at home during lockdown. Remember that it is thought that people with very mild disease, as well as healthy ones, can spread corona virus. Continue to wash hands, keep social distance, cover coughs and sneezes etc. at home. Take care to always wash your hands well after a trip outside of your home. Be especially careful if you are in your third trimester and rather let others do your shopping etc.

 

What are the implications for pregnant healthcare workers?

Before 28 weeks the same general principles regarding social distancing measures at work apply.  It will be impossible to completely avoid contact with COVID-19 patients in a clinical setting. Pregnant healthcare workers must follow the local guidance regarding the use of personal protective equipment (PPE). Be aware of the guidelines regarding so called aerosol generating procedures. It would be sensible to discuss this with your local hospital or practice and prevent taking part in this type of procedure without full PPE.

If you are after 28 weeks or have an underlying health condition we advise a more cautionary approach. It would be important to discuss changing your work environment to allow you to not have contact with anyone with symptoms of COVID-19 and to significantly reduce your social contact. Working from home, taking on more administrative duties and flexibility is advised.

Discuss your specific concerns at your next follow up with me or phone for advice.