Government of West Bengal Department of Health & Family Welfare State Family Welfare Bureau Swasthya Bhawan
GN 29, Sector V, Salt Lake, Kolkata – 700091.

FAQ on COVID-19 in Pregnancy (July 2021)

ANS: Though the incidence of Covid-19 in pregnancy is similar to the general population, absolute risk of severe Covid-19 in pregnancy was found not to be so much in the first wave. Form second wave, it is now established that pregnant women are at increased risk of severe Covid-19 associated illness compared to non-pregnant women.

 

1. What is the risk of Covid-19 infection in pregnant women in comparison to non

pregnant women?



2. What percentage of pregnant women infected with Covid infection is symptomatic?

ANS: In majority of cases women are asymptomatic (upto 70%) if universal screening is done. During the first wave, only 5-10% of the Covid positive women were symptomatic and only 1-2% had moderate to severe illness. In the second wave, the percentage of symptomatic women went up to 50-60% with 18-20% having moderate to severe illness.



Adverse effects on the mother, fetus, and the newborn infant are much more common among the symptomatic and those with moderate to severe disease.

3. Do the complications increase during pregnancy, if infected with Covid-19?

ANS: Not only the severity of diseases increase in Covid infected pregnancy, the following obstetrical complications also increase:



 Preeclampsia/Eclampsia  Preterm births

  Severe infection

  Gestational diabetes

  Thrombosis

  Severe perinatal morbidity

  Maternal morbidity and mortality
 There is more incidence of ICU admission and death

Complications are more pronounced with increased age and presence of co-morbidity e.g. chronic hypertension and pregestational diabetes etc.

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These adverse effects are much more pronounced in the third trimester and in symptomatic women. Even in asymptomatic women complications are more in comparison to non infected women.

4. What are the fetal outcomes in Covid-19 infected women?



ANS:

 There is no data suggesting any increased risk of miscarriage or loss of early pregnancy.  However, there is increased risk of preterm birth.
 Depending on the severity of the disease, there may be increase in fetal growth

restriction and intrauterine fetal death and stillbirth.

5. Is there any vertical transmission of Covid-19 infection? Is there any indication of MTP?

ANS:

 Vertical transmission of the Corona virus is uncommon, but there is a theoretical possibility of <3%.

 There is no indication of MTP on the grounds of the pregnant woman being RT-PCR positive.

 There is no significant reported increase in the incidence of congenital abnormalities (teratogenecity) among Covid-19 positive pregnant women; most reports are of infection in the third trimester.

 Drugs (Doxycycline, Ivermectin) often used in treatment of Covid-19 are contraindicated in pregnancy. Treating physicians should be aware of this.

 Transmission to neonates may occur during Perinatal period – (during labour or immediate post-partum period).

6. How would you classify Covid-19 infected pregnant women according to severity?

ANS: They are classified as:
 Asymptomatic – Covid positive, no symptom or sign.
 Mild – Uncomplicated upper respiratory infection (cough &/or Fever) WITHOUT

Breathlessness/ Hypoxia.

  Moderate – Respiratory rate ≥24/min AND/ OR SpO2< 94% in Room Air.

  Severe – Respiratory rate ≥ 30/min AND/ OR SpO2< 90% in Room Air.

In every infected mother pulse, temperature, respiratory rate, BP and oxygen saturation are checked periodically. Respiratory rate and oxygen saturation are preferably checked 4 hourly in symptomatic women.

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7. What are the admission criteria of a Covid -19 infected pregnant woman?

ANS:

 Women with mild Covid-19 disease without co-morbidity can be encouraged to remain at home (self isolation) in pregnancy consistent with routine care.

 Women with moderate to severe disease and mild with co-morbidity or other obstetric complications require admission – moderate cases in ward / HDU, and severe cases in ICU.

More than 90% of women recover without need of admission

8. Whatshouldbetheadviceduringhomeisolationandwhatarethemedicinestobeused

during home isolation?

ANS: Supportive Management should be advised:

  Mask, Hand Hygiene, Physical distancing, droplet precaution, separate room and toilet

  Monitor facility: SpO2, BP, Temp, Pulse, Sensorium.

  There should be caregiver.

  Medicines: Usual Iron, Folic Acid and Calcium supplementation. Inj. Tetanus Toxoid as

per schedule. Paracetamol (650 mg) thrice daily tablets, cough syrup in case of cough. Antibiotic is given as per Doctor’s advice. While prescribing antibiotics in pregnancy, safety must be considered.

 Though Vitamin C, Vitamin D and Zinc are used as empirical treatment for the Covid-19 patients, there are insufficient data regarding their effectiveness.

 Must have contact with State / District Telemedicine helpline and / or with an Obstetrician and a Physician.

  Fetal Kick count should be monitored by the women.

  Routine investigations for pregnancy are carried out.

  Investigations: CBC, CRP, LFT, CBG, Serum Urea / Creatinine, D-Dimer as suggested by

physician.

9. Warning Signs for which hospital admission is sought in patients under home isolation.

  Difficulty in breathing, Chest pain / tightness, severe cough.

  Resting tachycardia, SpO2 <94% (room air).

  Pain abdomen (onset of labour), dribbling per vagina, bleeding per vagina.

  Hospital admission, when advised by physician.

  Ivermectin and Doxycycline are contraindicated in pregnancy and lactation. Page 3 of 12

ANS:

10.What is the opinion regarding Ivermectin, Doxycycline, HCQ, and Azithromycin in

pregnancy?

ANS:



 Hydroxychloroquine, Chloroquine, Ivermectin and Azithromycin all are not approved by FDA for the treatment of Covid-19.



11.What are the general safety measures for ALL pregnant mothers during COVID-19

pandemic?

 Women should be advised to attend routine antenatal care, tailored to a minimum, usually at 12, 20, 28 and 36 weeks of gestation. The interval between visits should be at the discretion of the maternal care provider.

ANS:



  Fetal Kick count should be monitored in the interim period.

  If needed to visit health centre, should take own transport or call “102”, informing the

ambulance staff about her status. They may also contact the District / Block level helpline /

Control Room.
 Any woman who has a routine appointment delayed for more than 3 weeks should be

contacted. (In rural areas ANMs / ASHAs can contact by telephone/ routine household visits

with PPE).
 Routine antenatal investigations – Hb%, ABO, Rh, VDRL, Blood Sugar, POC test for HIV &

Syphilis, urine for R/E done.
 USG should be restricted to one at first trimester at 11-13 weeks, at second trimester for

anomaly scan at 18 weeks and one at third trimester if needed but not mandatory.
 To keep a good stock of essential supplies, including at least 30 days of any medications (so

that one doesn’t have to go out as often).
 To talk with an Obstetrician or other Health Care Provider over telephone, if there is any

question about health or development of Covid -19 symptoms and sign.

  To call or to attend hospital right away in case of need of emergency health care.

  For women who are self-quarantined because someone in their household has possible

symptoms of Covid-19, appointments should be deferred for 14 days.
 Even if a woman has previously tested negative for Covid-19, if she presents with symptoms

again, Covid-19 should be suspected.  General safety measures:

 To avoid the contact with other people as much as possible.
 To maintain at least 6 feet physical distancing, away from other people, if one needs to go

out.
 Wearing a mask or cloth in public and any other protection needed while at work.  To wash hands often with soap and water.
 To clean hands with a hand sanitizer.
 To avoid touching nose, eyes and mouth.

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12.Should routine Covid-19 testing be done in all pregnant women? If not, who should be

tested and which type of test done?

ANS: Routine Covid -19 testing is NOT required in all pregnant open. Testing is done in the

following categories of pregnant women depending on the discretion of caregiver.
1) Motherinsurveillanceincontainmentzonesandscreeningatpointsofentry– Testshouldbe



done irrespective of symptoms. Test in order of priority – RAT, RT-PCR or TrueNat or CBNAAT. 2) Surveillance in non-containment zones – Test is done if a) History of travel to a high risk area in last two weeks, b) Symptomatic, or c) Direct contact with a laboratory-confirmed case. Test in

order of priority – RT-PCR or TrueNat or CBNAAT, RAT
3) Hospital Settings – All pregnant women in or near labor who is hospitalized for delivery, test

should ideally be done. Test in order of priority -RT-PCR or TrueNat or CBNAAT, RAT.

NB:

 If RAT is positive it will be regarded as Covid-19 confirmed case, it need not be confirmed by other tests irrespective of symptom status.

 In case of RAT negative and the mother is symptomatic, further testing with RT-PCR, TrueNat, or CBNAAT is done to confirm.

  In asymptomatic woman if the RAT is negative further testing is decided on risk status.

  In hospitalized woman testing is not be done more than once. Testing should not be

ANS:

repeated as a discharge criterion.

13.What are the specific available therapies which are considered in a Covid positive

pregnant women?

  Oxygen therapy (should be maintained ≥95 percent)

  Prone position – Awake prone positioning is acceptable and feasible for pregnant women

in the left lateral decubitus position or the fully prone position in the second and early third

trimesters (avoided after 28 weeks)

  Antipyretics

  Antibiotics

  Venous thromboembolism prophylaxis

  Corticosteroids

  Remdesivir and Tocilizumab (see below)

  Other therapy like Convalescent plasma and Monoclonal antibody – their benefits and risks

are not established in pregnant women.

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14.What are the indications of steroid in Covid-19 positive pregnant mother? Which type

and what is the dose?

 Antenatal corticocosteroid (single course) for fetal lung maturity is prescribed in preterm labour/delivery as per existing protocol.

ANS:

  For treatment of Covid, steroids must be used as per the Covid Care protocol.

  Indications: Increasing Oxygen requirement, increasing inflammatory markers, within 48

hours of admission.
 Moderate disease: Dexamethasone 0.1 to 0.2 mg/kg can be given safely in indicated cases

of Covid-19 in pregnancy or IV Methylprednisolone 0.5-1 mg/kg for 3-5 days.
 Severe disease: Dexamethasone 0.2 to 0.4 mg/kg for 5-7days or IV Methyl Prednisolone 1-

2mg/kg in 2 (two) divided doses for 5-7 days.

For preterm labour cases, use of Dexamethasone is preferable over Methylprednisolone, as it serve dual purpose of treating Covid-19 and fetal lung maturity.

15.What are the indications of LMWH (Low Molecular Weight Heparin)?

 Thromboprophylaxis may be considered when there is altered coagulation profile (increase D-Dimer more than 2 times of ULN) and /or other high-risk conditions for maternal thrombosis.

ANS:



 Prophylactic LMWH (Low Molecular Weight Heparin) is given, unless birth is expected within 12 hours and it may be continued from 6 hours to 10 days post-partum.

16.What is the role of Remdesivir in pregnant mothers? What is the role of Tocilizumab

(Anti-IL6)?

 Remdesivir is advised as per the indications mentioned in the Covid Care Protocol, in severe cases and only under the care of a Covid Care specialist. Safety of drug during prgnancy is not yet established. Its use may override unknown fetal safety profile. Maternal need is more important here. Adequate counselling is needed.

ANS:



 Tocilizumab (interleukin-6 receptor antagonist) is used in covid positive non pregnant individual when the criteria i.e., hypoxia and systemic inflammation are met. Safety of Tocilizumab in pregnancy is not known. Decisions to administer in pregnancy must include shared decision-making between the pregnant individual, family and their health care provider.

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17.What are the investigations to be done in a Covid positive pregnant woman?

 Asymptomatic and mild – CBC, CRP, LFT, CBG, Serum Urea/Creatinine. D-Dimer may be done if CRP is raised or on a case to case basis as decided by the treating Physician.

ANS:

 Moderate – CBC, LFT, KFT, CRP, D-Dimer. In moderate disease, tests should be repeated 48-72 hourly or as decided by the treating Physician, on a case to case basis.

 Severe – CBC, KFT, LFT daily CRP & D-Dimer 24-48 hours.

Chest X-ray and HRCT are done very judiciously only in severe to moderate cases in worsening condition, using abdominal shield for fetal protection.
Other investigations e.g. LDH, Ferritin and IL-6 are reserved for indicated cases in moderate to severe infection.

18.What is the choice of route of delivery in Covid-19 positive women? What is about

induction of labour?

 Vaginal delivery is preferred. Caesarean Section should be done only for obstetric indications.

ANS:



 Induction of labor for appropriate medical or obstetrical indications in asymptomatic women should not be postponed or rescheduled. Covid infection per se is not an indication for induction of labor.

19.Anaesthesia – is there any preference?

ANS: If urgent delivery by Caesarean Section is needed, spinal or epidural anesthesia is recommended to minimize the hazards associated with general anesthesia. Always, aim is to keep the oxygen saturation above 94% during the procedure.



20.Is there any indications for termination of pregnancy, earlier before term?

ANS: In severe / critical disease, if it is expected that delivery may improve the respiratory failure and aid in optimization of clinical status, then termination is considered if gestation is more than 32 weeks. However, assessment should be done by a multidisciplinary team.



21.What is the Intra-natal care in Covid-19 positive women? Opinion regarding Early cord

clamping vs. Late cord clamping.

 Assessment of the severity of Covid-19 symptoms should be done, which should follow a multidisciplinary team approach including an Infectious Diseases or Medical Specialist.

ANS:



 Delivery should be preferably at a FRU hospital with a Covid-19 care facility with HDU/CCU

beds.

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 Caregivers should use full PPE kits during delivery and infection prevention protocol to be followed at all steps.



  Care should be taken that mother does not displace the mask in height of pain.

  Maternal observations including pulse, BP, temperature, respiratory rate & oxygen

saturations.

  Confirmation of the onset of labour, as per standard care.

  Electronic Fetal monitoring using Cardiotocograph (CTG) is preferable.

  Alternatively, a fetal Doppler device with digital display of fetal heart rate is acceptable.

  Hourly oxygen saturation monitoring during labour.

  Active Management of Third Stage of Labor (AMTSL) to be continued as per existing

guidelines.

  Delayed Cord Clamping to be continued as per existing guidelines.

  Close vigilance and monitoring during labour is mandatory, if maintenance of formal

Partograph is not possible
 Second stage – An individualized decision should be made regarding shortening the

length of the second stage of labour with elective instrumental birth in a symptomatic

pregnant woman who is becoming exhausted or hypoxic.
 In case of deterioration in the woman’s symptoms, an individual assessment is made

regarding the risks and benefits of continuing the labour versus emergency caesarean birth if this is likely to assist efforts to resuscitate the mother.

22.Postnatal care – Is breast feeding allowed in Covid positive woman? If so, what

precautions to be taken? Comments on Rooming in.

 Mother and healthy baby are kept together in the immediate postpartum period, if they do not otherwise require maternal critical care or neonatal care.

ANS:



  Rooming in is not contraindicated.

  But Bedding in should be avoided.

  There is no evidence of transmission of Covid-19 through breast milk.

  Women with Covid-19 should breastfeed with all standard precautions to prevent

transmission.
 Practice respiratory hygiene and wear a mask. Wash hands before and after touching the

baby. Routinely clean and disinfect surfaces. Coughing or sneezing on the baby while

feeding is to be avoided. Risk and benefit should be discussed with neonatologist
 If a woman with Covid-19 is too unwell to breastfeed or is admitted in ICU, she can be supported to safely provide her baby with breast milk in other ways, including by

expressing milk or donor human milk
 Neonates should not be covered with mask as it increases the rate of hypoxia and sudden



neonatal death.



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23.Is testing is mandatory in neonate born of Covid positive mother?

 Mother with Covid-19 detected within 14 days before or within 2 days after deliver testing by RT- PCR is done between 24-48 hours. Testing is avoided in the first 12 hours to minimize false positives due to superficial colonization.

ANS:



 Rooming-in should not be postponed if testing is delayed. In case of early discharge, take a pre-discharge sample.

 Testing protocol of neonate should be guided by Neonatologist / Pediatrician and prevailing guidelines.

24.How does Neonatal transmission of Covid occur?

  Transplacental passage from mother to fetus (intrauterine infection) – relatively rare.

  Intrapartum infection – Direct exposure to maternal blood or secretions during delivery,

ANS:



more common than the intrauterine transmission.
 Postnatal infection – Through aerosol or direct contact from infected mothers or

caregivers (including healthcare workers) – commonest.

25.What is the discharge protocol in Covid-19 positive antenatal and puerperal mother?

 Early discharge preferable to avoid overcrowding provided appropriate facilities are available at home.

ANS:



 Asymptomatic Covid-19 positive mothers without having any current obstetric emergency should preferably be discharged for home isolation with appropriate advice. Please follow the standard guidelines.

 For post-natal mothers who have no symptoms or mild symptoms usual discharge protocol should be followed and Covid-19 appropriate advice for home isolation for at least seven days should also be given.

 Mothers’ with moderate illness is discharged after 10 days of relief of symptoms. There is no need of repeat RTPCR.

 Only in severe cases RTPCR is done and discharge is given after it becomes negative. 26.Can Covid-19 Vaccination be given during pregnancy and lactation?

 As per notification by MoHFW, GOI on 19.05.2021 and subsequently endorsed by the State, Covid-19 vaccination is recommended for all lactating women.

ANS:



 Based on the recommendations of Expert Committee and wide stakeholders support, MoHFW, GOI has approved vaccination of pregnant women against Covid-19 on 02.07.2021 with the condition that the pregnant women may be informed about the risks

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of exposure to Covid-19 infection along with the risks and benefits associated with the Covid-19 vaccines available in the country.



  Experts are of the view that benefits outweigh the risks.

  Based on the information provided, a pregnant woman will have the choice to take the

vaccination so that she can take an informed decision.

 Covid-19 vaccine may be offered to the pregnant women if no contraindications exist.

 A pregnant woman, who opts for vaccination, could be vaccinated at any time of the pregnancy and at the earliest.

 Contraindications – The specific contraindications for pregnancy are anaphylactic or allergic reaction to the previous dose of Covid-19 vaccine/or to vaccines or injectable therapies, drugs, food-items etc. Vaccine is temporarily contraindicated in active Covid-19 infection, to defer for 12 weeks from infection or 4 to 8 weeks from recovery following Covid-19 infection, or Covid-19 infection treated with anti-Covid-19 monoclonal antibodies.



 Risks – Based on current knowledge, Covid-19 vaccines are unlikely to pose a risk to the pregnant woman or her fetus. A vaccine may have side effects like other drugs which are normally mild e.g. mild fever, pain at injection site, or feel unwell for 1-3 days. The long- term adverse effects and safety of vaccine for foetus and child is not established yet. Very rarely, (one in 1-5 lakh persons) the beneficiary may, after Covid-19 vaccination, experience some of the following symptoms within 20 days after getting the injection which may need immediate attention. These are shortness of breath (difficulty in breathing), chest pain, pain in limbs / pain on pressing the limbs or swelling in the limbs, petechial hemorrhage or bruising of the skin beyond the vaccination site, persistent abdominal pain with or without vomiting, seizures in the absence of previous history, severe and persistent headaches with or without vomiting (in the absence of previous history of migraine or chronic headache), weakness/paralysis of limbs or any particular side of the body, persistent vomiting without any obvious reason and blurred vision or pain in the eyes.

 

  Myth buster – An individual cannot get Covid-19 infection from vaccination.

  In case a woman has been infected with COVID-19 infection during the current pregnancy,

then she should be vaccinated soon after the delivery.

 WHO does not recommend pregnancy test before vaccination and delaying pregnancy or terminating pregnancy because of vaccination.

 It is advisable that a Covid-19 vaccine should be administered without any other vaccine, with a minimum interval of 14 days before or after administration of any other vaccine e.g. Td (Tetanus toxoid, Diphtheria) and influenza.

 Countries like Australia, Canada, Israel, Singapore, are already vaccinating pregnant

women with Covid-19 vaccines.

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27.Covid vaccination under special situations.

ANS:

1) In case of individuals having lab test proven SARS-2 Covid -19 illness, Covid -19 vaccination to be deferred by 3 months after recovery.

2) In case of individuals who have received at least the 1 dose and got Covid-19 infection before completion of the dosing schedule, the 2nd dose should be deferred by 3 months from clinical recovery from Covid-19 illness. st

3) In case of Covid-19 patients who have been given anti-SARS-2 monoclonal antibodies or convalescent plasma, Covid-19 vaccination to be deferred by 3 months from discharge from the hospital.

4) Persons with any other serious general illness requiring hospitalization or ICU care should also wait for 4-8 weeks before getting the Covid -19 vaccine.

28.A woman immediately after vaccination is found to be urinary pregnancy test positive.

She is asking if MTP is needed. What is your advice?

 Till date, there is no evidence to support that MTP is indicated for fear of adverse effect of vaccine in first trimester pregnancy. She should be explained and counselled. However, she must do the prenatal testing (11-13 weeks) and anomaly scan (18-19 weeks).

29.Other important notes on investigations:

ANS:



ANS: a. D-Dimer is nonspecific, especially in people with multiple co-morbidities and can be raised due to inflammation al one even in the absence of coagulation activation.

A. LABORATORY TESTS: D-DIMER & CRP.

b. No definite day for doing D-Dimer. Commonly after about 7 days of disease onset, when possibility of cytokine storm is highest. So, if condition deteriorates like decreasing oxygen saturation, D-Dimer should be done. If feasible, both CRP and D- Dimer should be done.

c. There is no cut off for CRP beyond which D-Dimer is indicated.
d. If D-Dimer is not possible, a CBC with CRP is good enough for guiding management.
e. If CBC shows altered N:L ratio and elevated CRP more than 5 times the upper limit of

normal, even if SpO2 is maintained, steroids are indicated to combat the cytokine

storm.
f. Even if D-Dimer is not available, red flag signs are sufficient to trigger use of LMWH

s/c in applicable doses.

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Imaging is important to assess moderate and severe cases and not mild ones.

B. IMAGING: CXR & HRCT.

a. CXR: In a case of positive RTPCR with classical symptoms, a CXR is hardly going to change the course of treatment. CXR like HRCT, might have a role in patients with negative microbiological diagnosis but strong suspicion of COVID, and in hospitalized patients especially follow up after an initial HRCT to note changes like pneumonitis, effusion and pneumothorax. However in setups where HRCT is not readily available and to have a Clinico-radiological diagnosis, an initial CXR has a role in patients where clinically indicated. No established role of serial CXR.

b. HRCT: In a resource scarce setup, it is not possible to advise HRCT in all cases; rather HRCT should be reserved for deteriorating patients. HRCT should be done at least 5 to 7 days after disease onset to note changes and to avoid false negative results. HRCT is to be followed up by CXR to minimize radiation exposure.

c. In Pregnancy, Abdominal Lead Shields to be used, as these tests are only done where the benefits to the mother are more important than the risks to the fetus.

 

Director of Health Services Govt. of West Bengal

Director of Medical Education Govt. of West Bengal

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