Interviewed by Antena 1: listen to the full interview here
Alexandra Matias, MD PhD Hab | Senior Consultant of Obstetrics and Gynaecology
Specialized in Fetal Medicine, Invasive Techniques and Anti-ageing
Associate Professor, Faculty of Medicine, Porto, Portugal
The new coronavirus (RNA virus) (SARS-CoV2) has an 80% similarity with the acute respiratory syndrome coronavirus (SARS-Co) (2002) and with the Middle East respiratory syndrome coronavirus (MERS-Co) (2012), both with zoonotic origin.
This virus has already reached 209 countries and infected more than 2 million people around the world, of which more than 150 thousand died. We still know little about it and are learning every day.
What extra precautions should a pregnant woman have in a Covid-19 context?
The incubation period of Covid-19 is between 2 and 14 days, but one can transmit the virus without presenting any symptoms. Although pregnant women are considered a risk group, their precautions are not much different from everyone else’s:
- Social isolations (avoid large groups) especially after 28 weeks (the period they are more susceptible, namely to prematurity)
- Respiratory social rules
- Frequent handwashing with soap for 20 seconds
- Frequent hand disinfection with alcohol solution
Is Covid-19 a danger for pregnant women?
Pregnant women suffer immunity and physiologic changes and may be more prone to more severe viral respiratory infections such as Covid-19. This fact has been verified with other infections related with coronavirus (including the acute respiratory syndrome coronavirus (SARS-Co), the Middle East respiratory syndrome coronavirus (MERS-Co) and other viral infections like the flu (influenza A).
However, until today, coronavirus does not seem to add morbidity nor increase the number of complications in infected pregnant women. The majority (around 86%) has mild to moderate symptoms, 8% have developed severe diseases and 1% critical diseases. It can provoke miscarriages in the first trimester and is related to prematurity of around 20% (that can also be iatrogenic). So far, it seems that no teratogen has been verified and the vertical transmission is very rare.
The General Health Directorate recommends that deliveries of infected mothers take place in a negative pressured surgery block. What does that mean?
A negative pressured system is a ventilation system that renews the air the entire time and the atmospheric pressure is kept lower than the rest of the hospital.
The goal is to restrain the contaminated air inside the room preventing its dissemination. The room is hermetically closed to keep the negative pressure: doors, water pluming and switches. This applies to deliveries and surgeries, namely laparoscopic.
Who can assist the delivery if the mother is infected?
The number of infected pregnant women is estimated to be less than 6 per 1000 infected Portuguese in the general population. In this case, which is a minority of pregnant women, the General Health Directorate recommends that the pregnancy follow up occurs in services with separate circuits for infected and non-infected pregnant women.
The positive Covid-19 cases with no symptoms or mild ones may benefit from medical supervision at home, providing there are conditions to do so. Otherwise, they can be admitted in the hospital or outside the hospital in facilities meant for that purpose. The moderate and severe cases should be admitted in hospitals with multidisciplinary teams.
During delivery and post-delivery isolation measures are advised, and that means no family visits whenever possible.
When entering the delivery room, pregnant women should be advised that:
- The presence of a companion will not be allowed
- The delivery routine is to be decided case by case
- There will not be physical contact with the newborn, which will be separated from the mother after the delivery
- The umbilical cord should be cut immediately after the delivery
Only the obstetrician, the paediatrician and the nurse previously appointed to the mother and equipped with individual protection equipment, level 2, will be in the delivery room during labor.
- Level 2 IPE is equipment of moderate design to a medium protection, for example:
- Specific protection equipment for hands and/or arms
- Specific protection equipment for feet and/or legs
- All equipment of total or partial protection of the face
The anesthetist, a second obstetrician and the surgery block team of nurses should wait outside.
The dry swab of the cord blood and the colostrum is to be collected as well as a fragment of the placenta and identified as a Covid-19 case. The placenta is sent to histopathological test (put into a large quantity of formalin and identified as a Covid-19 case).
The General Health Directorate recommends that newborns should be tested with 24 hours after delivery. All of them?
The newborn of a mother infected with the new coronavirus should be tested and it’s recommended that the test is made within the first 24 hours after birth.
Can a mother infected with the new coronavirus touch (skin to skin) and breastfeed her baby? Should she wear a mask?
As a principle, skin to skin contact is discouraged to the infected mother. However, if the mother is well clarified and still wishes the contact with the newborn, she should comply with rigorous hygiene of the hands, breasts and torso and use a surgery mask.
The option of skin contact and post-delivery accommodation (temporary separation or joint-rooming) should be made on a case to case basis and as a decision of the mother together with the health care team. And the latter must consider: the mother and the child’s clinical condition, the willing to breastfeed the baby, the resources available to either separate the newborn or to safely accommodate them together.
The possibility of breastfeeding should be discussed with the mother, but if she wants to do so she should since, apparently, the benefits are greater than the risks. There is no evidence that the virus is transmitted by breastfeeding. Nevertheless, for breastfeeding to be safe, the mother should always wear a mask and sanitize her breasts and hands while nursing.
When the mother is not capable of breastfeeding or when temporary distancing is established, mechanical extraction can be an alternative and the milk given by a healthy care giver.
At home, the infected mother and the baby should be separated from the family?
Yes, to avoid infecting the family. And it is important that the bathroom used is not shared with the family.
The babies that tested positive but do not present any symptoms can go home with the mothers. What precautions must the father have?
If the newborn tested positive but is clinically stable and asymptomatic, it may go home with the mother. It should be supervised for signs of fever, dehydration, lethargy and food tolerance, although these are all nonspecific signs.
When the newborn of a mother infected with Covid-19 is tested and the first result is negative, the General Health Directorate recommends that the test is repeated 48 hours later. In the case of hospitalized positive babies, the cure is determined by two negative tests with at least 24 hours apart and within 14 days of the beginning of the symptoms. In all other cases a single negative laboratory test after, at least, 14 days of the diagnosis suffices.
What sequelae can Covid-19 leave on a newborn?
Currently, there is no information about the long term effects of Covid-19 on infected babies or on babies exposed to it in the uterus. It is still unknown if newborns with SARS-CoV-2 present an added risk of severe complications, which is to expect because of their immunological prematurity, especially on premature newborns. However, until now, the few neonatal cases in China and Italy have not presented severe clinical scenarios. We know that in other age groups, Covid-19 is not just respiratory distress.
Even when the organism is trying to rebuild the lungs, in recovery, it creates scarring areas in the lesioned regions. The problem is that this scarring (fibrosis) may compromise the patient’s respiratory ability, in the long term. It can also affect the heart (Kawasaki-like synd.), the liver, kidneys, the brain and the endocrine and blood systems.
What are the most common worries of pregnant women?
They are afraid of infecting the baby, of going to medical appointments and of the delivery.
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