Pregnancy advise During Coronavirus

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Being pregnant can be a worrying time for any mother-to-be, even when all is well.

They have to avoid certain foods – no more soft cheese and shellfish, for instance – their bodies are changing dramatically and their normal routines can often be disrupted.

The United Kingdom is the latest of a number of countries to include pregnant women in the group of vulnerable people it is advising should “socially distance” themselves to reduce their chances of contracting coronavirus. Understandably, lots of pregnant women and their families have been left feeling worried and confused.

The bottom line is that we do not yet know enough about how the COVID-19 disease caused by the new coronavirus affects pregnancy to draw any definite conclusions, but small numbers of pregnant women have contracted the virus and there is enough known for us to advise extra precaution for women who are expecting.

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3 Can I pass it on by breastfeeding?

A weaker immune system

It was initially thought that during a pregnancy a woman’s immune system is weakened making her susceptible to infections. However, as with most things concerning the human body, it is not that simple and newer evidence suggests that a woman’s immune system is in a state of flux during her pregnancy, where at some points it is not as aggressive as normal and other times not.

This variable immune status during pregnancy is vital to accommodate the developing baby – for different reasons at different stages of pregnancy. For instance, in the early stages of pregnancy, the immune system has to adjust to allow for implantation of what is, after all, a foreign body. At other times, the immune system needs to adjust again but in a different way, for example when a woman’s body is preparing for labor.

This, of course, is an over-simplified explanation, but the point is that having a fluctuating immune system does put you at higher risk of the complications of COVID-19, such as respiratory difficulties and even pneumonia.

The first thing to stress is that women should still attend all their antenatal hospital appointments unless told otherwise by their doctor or midwife.

For now, there is no reason to change your birthing plan, whatever that maybe, if you have one. A birthing plan lays out what you are hoping for the birth – for example, whether you want to have your baby at home or in hospital, and what sorts of pain relief you might want to have.

However, if you develop symptoms that are consistent with coronavirus – a persistent dry cough or a high temperature – you must self-isolate and speak with your doctor or midwife.

Certainly, women who have other health conditions and are pregnant need to be extra vigilant and consider social distancing if not self-isolation during their pregnancy. Women who develop diabetes – a condition known as gestational diabetes – as a result of their pregnancy should also take care of and limit social contact.

Being diagnosed with gestational diabetes already puts you in a higher-risk pregnancy group even without the coronavirus, because it increases your chances of complications during pregnancy and birth. Furthermore, high levels of blood sugars for a prolonged period of time – the result if gestational diabetes is not diagnosed and managed properly – can weaken your immune system further.

For otherwise healthy pregnant women, given how the strength of their immune system varies during the trimesters, it would be prudent to take precautionary measures and consider social distancing where possible.

As a lot of pregnant women live with partners and perhaps have older children too, the same advice applies to the – practice social distancing so you do not put your pregnant wife, mother, sister or aunt at risk.

This might include working from home (for those who can do this), cutting back on social contact and avoiding crowded spaces.

General advice for pregnant women to help ensure a healthy pregnancy and as good immunity as possible is to stick to a good diet rich in iron (dark green leafy vegetables, fish and eggs) and folic acid (beans, pulses and green, leafy vegetables). A daily, pregnancy-specific multivitamin tablet may also help.

Can I pass coronavirus to my baby?

A question I am constantly being asked by my patients and their families is whether a pregnant woman who contracts COVID-19 could pass it on to her developing baby.

There are, indeed, lots of viral, bacterial and fungal infections that can be passed on to the baby during pregnancy, such as chickenpox, rubella, toxoplasmosis, hepatitis, and HIV.

However this is not the case for all viruses – some do get passed on, some do not.

There is currently no evidence to suggest that coronavirus can be passed to an unborn baby if the mother is infected.

A study published in The Lancet, the independent medical journal, which followed nine pregnant women who had tested positive for COVID-19 in China, found that none of their babies tested positive for the virus at birth (it is worth noting all the babies were born via cesarean section). Although these numbers are small, they are promising.

There was also no evidence of the virus being present in these women’s amniotic fluid – that is the fluid that surrounds and cushions the baby during pregnancy – as well as no evidence found in blood samples taken from the umbilical cord of each of the babies. This would suggest that normal, vaginal delivery is safe, but we cannot yet give a definitive answer about this as the numbers in the studies so far are so small.

All of this would suggest there is little evidence of babies contracting the virus from their mothers during the pregnancy.

Can I pass it on by breastfeeding?

It is less clear when it comes to breastmilk, however; we still cannot draw any real conclusions about whether or not breastmilk may carry the virus. 

Some viruses, such as HIV or cytomegalovirus (CMV), have been known to be transmitted in breastmilk but, so far, there is no evidence that COVID-19 itself can be.

The advice as it currently stands is for mothers who are free of the virus to continue breastfeeding their babies but to ensure good handwashing before the feed.

If the mother develops a temperature or cough, then she should consider using a breast pump to express her milk and allowing someone who is well to feed her baby until she feels better.

There is plenty of evidence that breast milk is good for your baby’s immune system and stopping it altogether may make them more susceptible to the virus.

As time goes on and, inevitably, more pregnant women do contract the virus, we will know more about how the virus behaves, but for now, taking sensible precautions – handwashing, social distancing, staying at home, not having visitors – is the most sensible course of action.

Q1. What effect does coronavirus have on pregnant women?

Generally, pregnant women do not appear to be more severely unwell than the general population if they develop coronavirus. As this is a new virus, how it may affect you is not yet clear. It is expected the large majority of pregnant women will experience only mild or moderate cold/flu-like symptoms.

More severe symptoms such as pneumonia appear to be more common in older people, those with weakened immune systems or long-term conditions.

If you are pregnant you are more vulnerable to getting infections than a woman who is not pregnant. If you have an underlying condition, such as asthma or diabetes, you may be more unwell if you have coronavirus.

If you develop more severe symptoms or your recovery is delayed this may be a sign that you are developing a more significant chest infection that requires enhanced care, and our advice remains that if you feel your symptoms are worsening or if you are not getting better you should contact your maternity care team or use the NHS 111 online service for further information and advice.

Q2. What effect will coronavirus have on my baby if I am diagnosed with the infection?

As this is a very new virus we are just beginning to learn about it. There is no evidence to suggest an increased risk of miscarriage. There is also no evidence that the virus can pass to your developing baby while you are pregnant (this is called vertical transmission). Two cases of possible vertical transmission have been reported. In both cases, it remains unclear whether the transmission was prior to or soon after birth. Another recent report from China of four women with coronavirus infection when they gave birth found no evidence of the infection in their newborn babies. An expert opinion is that the fetus is unlikely to be exposed during pregnancy. It is also therefore considered unlikely that if you have the virus it would cause abnormalities in your baby and none have been observed currently.

Some babies born to women with symptoms of coronavirus in China have been born prematurely. It is unclear whether coronavirus caused this or the doctors to make the decision for the baby to be born early because the woman was unwell. As we learn about the risk of pre-term birth and coronavirus infection, we will update this information.

Q3. What can I do to reduce my risk of catching coronavirus?

The most important thing to do is to wash your hands regularly and effectively as soon as you come from public places to your home or workplace. There is useful advice on the NHS website on the best way to reduce any infection risk, not just for coronavirus, but for other things like colds and flu.

Questions 4-7 added following the announcement on 16 March 2020 that pregnant women have been placed in a ‘vulnerable group’

Q4. Why are pregnant women in a vulnerable group?

A pregnant woman was placed in a vulnerable group by the Chief Medical Officer on 16th March. This means you have been advised to reduce social contact through social distancing measures.

Based on the evidence we have so far, pregnant women are still no more likely to contract coronavirus than the general population. What we do know is that pregnancy in a small proportion of women can alter how your body handles severe viral infections. This is something that midwives and obstetricians have known for many years and are used to dealing with. As yet, there is no evidence that pregnant women who get this infection are more at risk of serious complications than any other healthy individuals.

What has driven the decisions made by officials is a desire to be very cautious about pregnant women. We know that some viral infections are worse in pregnant women. At the moment, there’s no evidence that this is the case for coronavirus infection, but the amount of evidence is still quite limited.

Q5.What do I need to do now?

All pregnant women should follow the PHE advice:

  • Guidance on social distancing for all vulnerable people including pregnant women
  • Guidance for individuals and households with possible coronavirus infection

Q6. Can I still go to work?

Pregnant women who can work from home should do so. If you can’t work from home, if you work in a public-facing role that can be modified appropriately to minimize your exposure, this should be considered and discussed with your occupational health team.

More detailed advice for pregnant women, including those who cannot work from home, such as healthcare workers, is being developed and will be made available as soon as possible.

Q7. Should I attend my antenatal appointments?

Attending antenatal and postnatal care when you are pregnant and have a new baby is essential to ensure the wellbeing of you and your baby.

If you are well, you should attend your antenatal care as normal. If you have symptoms of possible coronavirus infection, you should postpone routine visits until after the isolation period is over.

The following practical advice may be helpful:

  1. If you have a routine scan or visit due in the coming days, please contact your maternity unit for advice and a plan. You will still need to attend for a visit but the appointment may change due to staffing requirements.
  2. Some appointments may be conducted on the telephone or using videoconferencing, provided there is a reasonable expectation that maternal observations or tests are not required.
  3. If you are between appointments, please wait to hear from your maternity team.
  4. If you are attending more regularly in pregnancy, then your maternity team will be in touch with plans.
  5. If you miss an appointment and haven’t heard from your maternity team, please contact them to rearrange the appointment.

Whatever your personal situation please consider the following:

  1. If you have any concerns you will still be able to contact your maternity team but please note they may take longer to get back to you
  2. If you have an urgent problem related to your pregnancy but not related to coronavirus, get in touch using the same emergency contact details you already have. Please do not contact this number unless you have an urgent problem
  3. If you have symptoms suggestive of coronavirus contact your maternity services and they will arrange the right place and time to come for your visits. You should not attend a routine clinic.
  4. You will be asked to keep the number of people with you at appointments to a minimum, including children.
  5. There may be a need to reduce the number of antenatal visits. This will be communicated to you. Do not reduce your number of visits without agreeing first with your maternity team.

Q8. What is travel advice if I am pregnant?

If you are in the UK, you should follow the advice given by the Foreign and Commonwealth Office, which is being regularly updated in line with the evolving situation.

All individuals, including pregnant women, should ensure they have adequate insurance arrangements prior to travel. You should also check that your travel insurance will provide cover for birth and care of your newborn baby if you give birth while abroad.

Q9. What should I do if I think I may have coronavirus or been exposed?

If you are pregnant and you have either:

  • a high temperature
  • a new, continuous cough

You should stay at home for 7 days. Do not go to a GP surgery, pharmacy or hospital. You do not need to contact NHS 111 to tell them you are staying at home. You do not need a test for coronavirus. At the present time, only people with severe symptoms who require overnight admission to the hospital will be tested.
You should contact your maternity unit to inform them that you have symptoms suggestive of coronavirus, particularly if you have any routine appointments in the next 7 days.

You should use the NHS 111 online coronavirus service, or call NHS 111 if:

  1. you feel you cannot cope with your symptoms at home
  2. your condition gets worse
  3. your symptoms do not get better after 7 days

If you have concerns about the wellbeing of yourself or your unborn baby during your self-isolation period, contact your midwife or, out-of-hours, your maternity team. They will provide further advice, including whether you need to attend the hospital.

Q10. How will I be tested for coronavirus?

The process for diagnosing coronavirus infection is changing rapidly. At the current time, only people with severe symptoms who require at least overnight admission to the hospital will be tested.

If you do require a test, you will be tested in the same way as anyone being tested, regardless of the fact that you are pregnant. Currently, the test involves swabs being taken from your mouth and nose. You may also be asked to cough up sputum, a mixture of saliva and mucus.

Q11. What should I do if I test positive for coronavirus?

If you test positive for coronavirus, you should contact your midwife or antenatal team to make them aware of your diagnosis. If you have no symptoms or mild symptoms, you will be advised to recover at home. If you have more severe symptoms, you might be treated in a hospital setting.

Q12. Why would I be asked to self-isolate (as opposed to reducing social contact)?

You may be advised to self-isolate because:

  • You have symptoms of coronavirus, such as a high temperature or new, continuous cough
  • You have tested positive for coronavirus and you’ve been advised to recover at home

Q13. What should I do if I’m asked to self-isolate?

Pregnant women who have been advised to self-isolate should stay indoors and avoid contact with others for 7 days. If you live with other people, they should stay at home for at least 14 days, to avoid spreading the infection outside the home.

The NHS guidance on self-isolation currently recommends people should:

  1. Not go to school, work, NHS settings or public areas
  2. Not use public transport
  3. Stay at home and not allow visitors
  4. Ventilate the rooms where they are by opening a window
  5. Separate themselves from other members of their household as far as possible, using their own towels, crockery, and utensils and eating at different times
  6. Use friends, family or delivery services to run errands, but advise them to leave items outside.

You may wish to consider online fitness routines to keep active, such as pregnancy yoga or Pilates.

Q14. Can I still attend my antenatal appointments if I am in self-isolation?

You should contact your midwife or antenatal clinic to inform them that you are currently in self-isolation for possible/confirmed coronavirus and request advice on attending routine antenatal appointments.

It is likely that routine antenatal appointments will be delayed until isolation ends. If your midwife or doctor advises that your appointment cannot wait, the necessary arrangements will be made for you to be seen. For example, you may be asked to attend at a different time, or in a different clinic, to protect other patients.

Q15. How will my care be managed after I have recovered from coronavirus?

If you have confirmed coronavirus infection, as a precautionary approach, an ultrasound scan will be arranged 14 days after your recovery, to check that your baby is well. This 14 day period may be reduced as more information on how infected people are as they recover becomes available.

If you have recovered from coronavirus and tested negative for the virus before you go into labor, where and how you give birth will not be affected by your previous illness.

Q16. What do I do if I feel unwell or I’m worried about my baby during self-isolation?

Pregnant women are advised not to attend maternity triage units or A&E unless in need of urgent pregnancy or medical care.

If you have concerns about the wellbeing of yourself or your unborn baby during your self-isolation period, contact your midwife or, out-of-hours, your maternity team. They will provide further advice, including whether you need to attend the hospital.

If attendance at the maternity unit or hospital is advised, pregnant women are requested to travel by private transport, or arrange hospital transport, and alert the maternity triage reception once on the premises, prior to entering the hospital.

Q17. Will being in self-isolation for suspected or confirmed coronavirus affect where I give birth?

As a precautionary approach, pregnant women with suspected or confirmed coronavirus when they go into labor, are being advised to attend an obstetric unit for birth, where the baby can be monitored using continuous electronic fetal monitoring, and your oxygen levels can be monitored hourly.

Continuous fetal monitoring is to check how your baby is coping with labor. As continuous fetal monitoring can only take place in an obstetric unit, where doctors and midwives are present, it is not currently recommended that you give birth at home or in a midwife-led unit, where only midwives would be present.

We will keep this advice continually updated as new evidence emerges.

Q18. Will being in self-isolation for suspected or confirmed coronavirus affect how I give birth?

There is currently no evidence to suggest you cannot give birth vaginally or that you would be safer having a cesarean birth if you have suspected or confirmed coronavirus, so your birth plan should be followed as closely as possible based on your wishes.

However, if your respiratory condition (breathing) suggests that urgent delivery is needed, a cesarean birth may be recommended.

It is not recommended that you give birth in a birthing pool in the hospital if you have suspected or coronavirus, as the virus can sometimes be found in feces. It may also be more difficult for healthcare staff to use adequate protection equipment during a water birth.

There is no evidence that women with suspected or confirmed coronavirus cannot have an epidural or a spinal block. In our previous version of the guidance, it was suggested that the use of Entonox (gas and air) may increase aerosolization and spread of the virus, but a review of the evidence suggests there is no evidence that Entonox is an aerosol-prone procedure, so there is no reason you cannot use this in labor.

Q19. What happens if I go into labor during my self-isolation period?

If you go into labor, you should call your maternity unit for advice, and inform them that you have suspected or confirmed coronavirus infection.

If you have mild symptoms, you will be encouraged to remain at home (self-isolating) in early labor, as per standard practice.

Your maternity team has been advised on ways to ensure that you and your baby receive safe, quality care, respecting your birth plan as closely as possible.

When you and your maternity team decide you need to attend the maternity unit, general recommendations about hospital attendance will apply:

  1. You will be advised to attend hospital via private transport where possible, or call 111/999 for advice, as appropriate
  2. You will be met at the maternity unit entrance and provided with a surgical face mask, which will need to stay on until you are isolated in a suitable room
  3. Coronavirus testing will be arranged
  4. Your birth partner(s) will be able to stay with you throughout, but visitors should be kept to a minimum

Q20. Could I pass coronavirus to my baby?

As this is a new virus, there is limited evidence about managing women with coronavirus infection in women who have just given birth; however, there are no confirmed reports of women diagnosed with coronavirus during the third trimester of pregnancy have passed the virus to their babies while in the womb.

Q21. Will my baby be tested for coronavirus?

Yes, if you have suspected or confirmed coronavirus at the time your baby is born, your baby will be tested for coronavirus.

Q22. Will I be able to stay with my baby/give skin-to-skin if I have suspected or confirmed coronavirus?

Yes, if that is your choice. Provided your baby is well and doesn’t require care in the neonatal unit, you will be kept together after you have given birth.

There are some reports from China which suggest women with confirmed coronavirus have been advised to separate from their baby for 14 days. However, this may have potentially negative effects on feeding and bonding.

A discussion about the risks and benefits should take place between you and your family and the doctors caring for your baby (neonatologists) to individualize care for your baby.

This guidance may change as knowledge evolves.

Q23. Will I be able to breastfeed my baby if I have suspected or confirmed coronavirus?

Yes. At the moment there is no evidence that the virus can be carried in breastmilk, so it’s felt that the well-recognized benefits of breastfeeding outweigh any potential risks of transmission of coronavirus through breastmilk.

The main risk of breastfeeding is close contact between you and your baby, as you may share infective airborne droplets, leading to infection of the baby after birth.

A discussion about the risks and benefits of breastfeeding should take place between you and your family and your maternity team.
This guidance may change as knowledge evolves.

If you choose to breastfeed your baby, the following precautions are recommended:

  1. Wash your hands before touching your baby, breast pump or bottles
  2. Try to avoid coughing or sneezing on your baby while feeding at the breast
  3. Consider wearing a face mask while breastfeeding, if available
  4. Follow recommendations for pump cleaning after each use
  5. Consider asking someone who is well to feed your expressed breast milk to your baby.

If you choose to feed your baby with formula or expressed milk, it is recommended that you follow strict adherence to sterilization guidelines. If you are expressing breast milk in the hospital, a dedicated breast pump should be used.

Q24. What is the advice if I am a healthcare worker and pregnant?

We understand that it must be an anxious time if you work in healthcare and you are pregnant, especially following the Chief Medical Officer’s advice on 16 March 2020 for all pregnant women to minimize social contact as a precautionary measure. To the best of our knowledge, most pregnant healthcare professionals are no more personally susceptible to catching the virus than their non-pregnant colleagues.

There is no convincing evidence that coronavirus infection can affect your baby’s growth, but as other similar viruses have been known to cause fetal growth restriction, an extra ultrasound scan 14 days later is advised, as a precaution.

If you become unwell due to infection with coronavirus, it may occasionally be necessary to deliver your baby early to help you to recover. In this situation, the baby may need to be delivered prematurely.

You should discuss your individual circumstances with your local Occupational Health department.

Further guidance for pregnant healthcare workers is being sought urgently and will be published in our next update to the guidance.

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