Preventive measures and management of COVID-19 in pregnancy

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Drugs & Therapy Perspectives
https://doi.org/10.1007/s40267-020-00725-x
COMMENTARY
Preventive measures andmanagement ofCOVID-19 inpregnancy
SumairaOmer1· SalamatAli2· Zaheer udDinBabar3
© Springer Nature Switzerland AG 2020
Introduction
The novel severe acute respiratory syndrome (SARS) coro-
navirus 2 (SARS-CoV-2; also known as 2019-nCoV) has
played havoc worldwide, beginning with Wuhan, China in
December 2019. As of 17 March 2020, there are 153 coun-
tries who have reported cases of infection caused by this
virus [i.e., coronavirus disease-2019 (COVID-19)], with
Italy becoming the new epicentre [1]. COVID-19 is a global
public health emergency, and could cause devastating health
issues during pregnancy. Pregnant women have a high pro-
pensity to acquire this infection due to their altered physi-
ological and immunological function.
Previous studies have indicated that SARS during gesta-
tion is linked with a high risk of spontaneous miscarriage,
preterm birth and intrauterine growth restriction [2]. To date,
studies in pregnant women with COVID-19 have indicated
few maternal and neonatal complications [3], but more con-
crete evidence is required as these studies involved a small
number of women over a short period [4]. Importantly, viral
respiratory illnesses, such as influenza, can easily develop
during pregnancy, which means pregnant women may be
more vulnerable to COVID-19 and require prioritized medi-
cal care.
Interim COVID-19 guidelines for the effective counsel-
ling and education of pregnant women are currently avail-
able from the Centers for Disease Control and Prevention
(CDC) and the World Health Organization (WHO) [5,
6]. Recommendations, which were published following
the COVID epidemic in Wuhan, are also available from
Chinese experts [7, 8]. This commentary reviews the avail-
able information on managing COVID-19 during pregnancy
to preserve the health of mothers and children in this critical
situation.
Characteristics andtransmission
of2019-nCoV
2019-nCoV is an RNA single-stranded, non-segmented,
enveloped virus belonging to a diverse group of viruses that
are zoonotic (i.e., they are pathogens that can live in both
animals and humans). Until now, seven corona viruses have
been identified that could infect humans [9]. SARS-CoV-1
and Middle East respiratory syndrome coronavirus (MERS-
CoV), two deadly pathogens, belong to the same viral group
as 2019-nCoV. As this pathogen has a receptor-binding
domain structure similar to that of SARS-CoV-1, it is likely
that COVID-19 and SARS have a similar pathogenesis [10].
These viruses appear to be mainly spread via person-to-
person contact [11]. The route of transmission is primarily
via respiratory droplets from the infected person into air,
which are then deposited onto nearby surfaces. The virus
could potentially transfer to individuals within a distance
of < 2m (6 feet) of the infected person [12]. As the virus can
survive on non-living surfaces, it is essential to frequently
clean touched surfaces [13]. To date, no medications or
vaccines are approved to treat or prevent COVID-19 [14].
Therefore, implementation of preventive measures is impor-
tant to avoid its further spread.
Symptoms anddiagnosis ofCOVID-19
The onset of symptoms is usually within 14days of expo-
sure. COVID-19 symptoms range from mild to severe, and
commonly include shortness of breath, cough, myalgia, fever
and severe pneumonia. Injury to vital organs (kidney, heart,
liver) has also been observed [15]. The severity of infection
may depend on the underlying health of the individual [16],
with patients with pre-existing illnesses, such as diabetes
* Sumaira Omer
sammaraomer@gmail.com
1 Department ofPharmacy Administration andClinical
Pharmacy, Xian Jiatong University, Xi’an, China
2 Services Institute ofMedical Sciences, Lahore, Pakistan
3 Centre ofPharmaceutical Policy andPractice Research,
University ofHuddersfield, Huddersfield, WestYorkshire,
UK

and lung disease, as well as the elderly, being more prone to
the rapid development of COVID-19.
Diagnosis of COVID-19 is mainly based on computed
tomography (CT) scans and reverse transcription polymerase
chain reaction (RT-PCR). This test is routinely employed
for the detection of viruses responsible for respiratory ill-
nesses [17]. In the RT-PCR technique, viral isolates are used
as a primary substrate to perform an assay that identifies
a specific virus and its gene sequence [18]. A CT scan is
considered more sensitive than RT-PCR, and can be used to
confirm a positive RT-PCR test [19]. To conduct RT-PCR,
a sample taken from throat swabs, urine, saliva or stool can
be used. Usually the nucleic acid test is repeated for a sin-
gle patient in order to get accurate results. Two tests are
performed successively at a gap of 24h when the virus is
not observed in the throat swab sample. If RT-PCR is not
available, a serological test could also be use for diagnostic
examination [15].
Precautionary measures duringpregnancy
Preventive measures, including frequent hand washing,
refraining from excessive outdoor activities unless an emer-
gency, and avoiding infected individuals, crowded places
and public gatherings, should be strictly followed by preg-
nant women. They should check their temperature regularly
and immediately inform their doctor if they experience
shortness of breath, cough or fever [14]. Moreover, women
who have a travel history or COVID-19 symptoms should
be kept in isolation for at least 14days. The National Health
Commission of China proposed that neonates from mothers
who are confirmed or suspected cases should be kept under
observation and not breastfed [8]. However, no evidence is
currently available to confirm the transfer of 2019-nCoV to
breast milk.
Pregnant women should closely monitor their vital signs
(pulse rate, respiration rate and temperature). Importantly,
they should inform their maternity-care provider regarding
their health status and seek advice regularly. Extracorpor-
eal membrane oxygenation and oxygen inhalation (60–100%
concentration with a flow rate of 40L/min) should be used
if hypoxia occurs [15].
Managing COVID-19 inpregnancy
For effective management, pregnant women with suspected
COVID-19 should be isolated and then transferred to a
hospital equipped with sufficient health facilities and fully
trained clinicians to take proper care of critically ill obstet-
ric patients. In order to provide appropriate treatment after
complete examination [15], pregnant women can usually be
categorized as having:
• Mild disease (i.e., symptomatic with stable vital signs).
• Severe disease (i.e., respiration rate ≥ 30/min, resting
saturated O2 ≤ 93%, arterial blood oxygen partial pres-
sure/oxygen concentration ≤ 300mmHg).
• Critical disease (i.e., shock with organ failure, respira-
tory failure requiring mechanical ventilation or refrac-
tory hypoxaemia requiring extra-corporal membrane
oxygenation).
Pharmaceutical care
No drug is currently approved to treat COVID-19, and
presently, there is no effective coronavirus drug, and
unethical usage of drugs should be avoided [7]. However,
twice-daily antiviral treatment with lopinavir/ritonavir
(400mg/100mg) + α-interferon (5 million IU in 2mL of
sterile water for injection) has shown improvements in clini-
cal condition in some cases [15]. This regimen may also
be used to treat pregnant women, despite lopinavir/ritonavir
being a pregnancy category C drug (i.e., use in pregnancy
only when the potential benefits outweigh the potential
risks).
COVID-19 causes extensive alveolar damage, which, in
turn, increases the risk of secondary bacterial infection. On
confirmation of secondary bacterial infection, intravenous
ceftriaxone should be administered [15].
Corticosteroids should not be used to treat COVID-19, as
they obstruct the clearance of virus from the body. There-
fore, methylprednisolone should be used cautiously and only
in critically ill patients with hypoxic conditions [15].
Neonatal care
2019-nCoV is extremely contagious [20]. It may have a dis-
astrous health impact on neonates, causing symptoms such
as respiratory distress (shortness of breath), high heart rate
and gastrointestinal distress. Reportedly, initial symptoms
of neonates from infected mothers were shortness of breath,
cough and fever, but vertical transmission of infection (the
transfer of the pathogen from infected mother to infant dur-
ing the period before or after birth, particularly via germ cell
and placental blood) has not been confirmed [3, 7]. Based on
the results of a retrospective study of ten neonates born to
nine pregnant woman with confirmed COVID-19 in China,
vertical transmission of 2019-nCov to neonates has not yet
been confirmed [3]. To decrease the risk of vertical transmis-
sion, delayed cord clamping (DCC) is not recommended.
Moreover, mother–baby contact is also not advisable [7].
However, as a precautionary measure, neonates should be
kept isolated for 14days. When breastfeeding, it is advisable

to use a breast pump to minimize the risk of transmitting the
infection [21].
What concerns need tobe addressed?
Viral infections pose serious consequences for maternal
and neonatal health. Over the last 2 decades, human life
was threatened by infections caused by SARS-CoV-1 and
MERS-CoV, but 2019-nCoV is responsible for more illness
than these viruses. Thus far, it appears that the clinical pres-
entation of COVID-19 does not differ between pregnant and
non-pregnant women [22]. Although more robust research is
required, fears regarding the vertical transmission of 2019-
nCoV and/or teratogenicity should not lead to abortion.
Preventive anti-viral measures must be properly imple-
mented to avoid further spreading of 2019-nCoV and,
therefore, of COVID-19. Everyone should maintain basic
personal hygiene. Initial screening should be performed
at hospital entrances, and suspected cases should be iso-
lated. Special attention, as well as prioritized care, should
be offered to pregnant women based on their health status.
Healthcare professionals should be given specialized cloth-
ing and equipment, and should follow the standard proce-
dure for donning, doffing and disposal of personal protective
equipment [23].
Finally, collaboration between nations is imperative to
tackle the burden of COVID-19. Experts and healthcare
professionals should share useful information and effective
schemes to curb the rate of outbreaks, especially in regions
with few health facilities. Surveillance systems for reporting
all significant maternal and fetal data in pregnant women
with COVID-19 should also be established.
Take home messages
• Keep up to date with the latest COVID-19 information
and guidelines from the CDC and WHO.
• Take preventive measures, specifically in pregnant
women, to control further spread of COVID-19.
• Focus on symptomatic treatment, as there is no recom-
mended treatment for COVID-19.
• Promote effective communication between healthcare
professionals to detect suspected COVID-19 during preg-
nancy.
• Provide prioritized care for pregnant women, thereby pre-
venting further promulgation of the infection in neonates.
Author contributions SO and ZDB designed the initial concept. SO
and SA made substantial contributions during report collection and
writing. ZDB provided expert advice regarding relevant studies.
Finally, all authors reviewed the drafts prior to submission.
Compliance with ethical standards
Funding No funding was received for the preparation or publication
of this article.
Conflict of interest The authors declare no conflicts of interest.
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