ArticlePDF Available

ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals

Ultrasound Obstet Gynecol 2020
Published online in Wiley Online Library ( DOI: 10.1002/uog.22013 INTERIM GUIDANCE
ISUOG Interim Guidance on 2019 novel coronavirus
infection during pregnancy and puerperium: information
for healthcare professionals
In response to the World Health Organization (WHO)
statements and international concerns regarding the novel
coronavirus infection (COVID-19) outbreak, the Interna-
tional Society of Ultrasound in Obstetrics and Gynecology
(ISUOG) is issuing the following guidance for manage-
ment during pregnancy and puerperium.
With the current uncertainty regarding many aspects of
the clinical course of COVID-19 infection in pregnancy,
potentially valuable information is likely to be obtained
by obstetricians and ultrasound practitioners that may
help in counseling pregnant women and further improve
our understanding of the pathophysiology of COVID-19
infection in pregnancy. This statement is not intended to
replace previously published interim guidance on evalu-
ation and management of COVID-19-exposed pregnant
women. It should, therefore, be considered in conjunction
with other relevant advice from organizations such as:
Centers for Disease Control and Prevention (CDC):
Pan American Health Organization (PAHO):
European Centre for Disease Prevention and Control
Public Health England:
National Health Commission of the People’s Republic
of China:
Perinatal Medicine Branch of Chinese Medical Associa-
Indicazioni ad interim della Societa Italiana di Neona-
tologia (SIN):
e Publique France https://www.santepubliquefran
Sociedad Espa ˜
nola de Ginecolog´
ıa y Obstetricia
Royal College of Obstetricians and Gynaecolo-
gists (RCOG):
The novel coronavirus infection (COVID-19), also termed
SARS-CoV-2, is a global public health emergency. Since
the first case of COVID-19 pneumonia was reported in
Wuhan, Hubei Province, China, in December 2019, the
infection has spread rapidly to the rest of China and
Coronaviruses are enveloped, non-segmented, positive-
sense ribonucleic acid (RNA) viruses belonging to the
family Coronaviridae, order Nidovirales4. The epidemics
of the two β-coronaviruses, severe acute respiratory syn-
drome coronavirus (SARS-CoV) and Middle East respira-
tory syndrome coronavirus (MERS-CoV), have caused
more than 10 000 cumulative cases in the past two
decades, with mortality rates of 10% for SARS-CoV
and 37% for MERS-CoV59. COVID-19 belongs to the
same β-coronavirus subgroup and it has genome sim-
ilarity of about 80% and 50% with SARS-CoV and
MERS-CoV, respectively10. COVID-19 is spread by res-
piratory droplets and direct contact (when bodily fluids
touch another person’s eyes, nose or mouth, or an open
cut, wound or abrasion). The Report of the World Health
Organization (WHO)-China Joint Mission on Coron-
avirus Disease 2019 (COVID-19)11 estimated a high R0
(reproduction number) of 22.5. The latest report from
rd, estimated the global mortality
rate of COVID-19 infection to be 3.4%.
Huang et al.1first reported on a cohort of 41 patients
with laboratory-confirmed COVID-19 pneumonia. They
described the epidemiological, clinical, laboratory and
radiological characteristics, as well as treatment and clin-
ical outcome of the patients. Subsequent studies with
Copyright ©2020 ISUOG. Published by John Wiley & Sons Ltd. IS U O G IN T E RI M GU I D AN C E
2ISUOG Interim Guidance
larger sample sizes have shown similar findings13,14.The
most common symptoms reported are fever (43.8% of
cases on admission and 88.7% during hospitalization)
and cough (67.8%)15. Diarrhea is uncommon (3.8%).
On admission, ground-glass opacity is the most common
radiologic finding on computed tomography (CT) of the
chest (56.4%). No radiographic or CT abnormality was
found in 157 of 877 (17.9%) patients with non-severe
disease and in five of 173 (2.9%) patients with severe
disease. Lymphocytopenia was reported to be present in
83.2% of patients on admission15.
Pregnancy is a physiological state that predisposes
women to respiratory complications of viral infection.
Due to the physiological changes in their immune and car-
diopulmonary systems, pregnant women are more likely
to develop severe illness after infection with respiratory
viruses. In 2009, pregnant women accounted for 1% of
patients infected with influenza A subtype H1N1 virus,
but they accounted for 5% of all H1N1-related deaths16.
In addition, SARS-CoV and MERS-CoV are both known
to be responsible for severe complications during preg-
nancy, including the need for endotracheal intubation,
admission to an intensive care unit (ICU), renal failure
and death9,17. The case fatality rate of SARS-CoV infec-
tion among pregnant women is up to 25%9. Currently,
however, there is no evidence that pregnant women are
more susceptible to COVID-19 infection or that those
with COVID-19 infection are more prone to developing
severe pneumonia.
Over and above the impact of COVID-19 infection on
a pregnant woman, there are concerns relating to the
potential effect on fetal and neonatal outcome; therefore,
pregnant women require special attention in relation to
prevention, diagnosis and management. Based on the
limited information available as yet and our knowl-
edge of other similar viral pulmonary infections, the
following expert opinions are offered to guide clinical
Case definitions are those included in the WHO’s
interim guidance, ‘Global surveillance for COVID-19 dis-
ease caused by human infection with the 2019 novel
Suspected case
A patient with acute respiratory illness (fever and at
least one sign/symptom of respiratory disease (e.g.
cough, shortness of breath)) AND with no other etiol-
ogy that fully explains the clinical presentation AND
a history of travel to or residence in a country/area
or territory reporting local transmission of COVID-19
infection during the 14 days prior to symptom onset;
A patient with any acute respiratory illness AND who
has been in contact (see definition of contact below)
with a confirmed or probable case of COVID-19 infec-
tion in the 14 days prior to onset of symptoms; OR
A patient with severe acute respiratory infection (fever
and at least one sign/symptom of respiratory disease
(e.g. cough, shortness breath)) AND who requires hos-
pitalization AND who has no other etiology that fully
explains the clinical presentation.
Probable case
A suspected case for which laboratory testing for
COVID-19 is inconclusive.
Confirmed case
A person with laboratory confirmation of COVID-19
infection, irrespective of clinical signs and symptoms.
It is plausible that a proportion of transmissions occurs
from cases with mild symptoms that do not provoke
healthcare-seeking behavior. Under these circumstances,
in areas in which local transmission occurs, an increasing
number of cases without a defined chain of transmis-
sion is observed19 and a lower threshold for suspicion in
patients with severe acute respiratory infection may be
recommended by health authorities.
Any suspected case should be tested for COVID-19
infection using available molecular tests, such as
quantitative reverse transcription polymerase chain
reaction (qRT-PCR). Lower-respiratory-tract specimens
likely have a higher diagnostic value compared
with upper-respiratory-tract specimens for detecting
COVID-19 infection. The WHO recommends that, if
possible, lower-respiratory-tract specimens, such as spu-
tum, endotracheal aspirate or bronchoalveolar lavage,
be collected for COVID-19 testing. If patients do not
have signs or symptoms of lower-respiratory-tract dis-
ease or specimen collection for lower-respiratory-tract
disease is clinically indicated but collection is not possible,
upper-respiratory-tract specimens of combined nasopha-
ryngeal and oropharyngeal swabs should be collected. If
initial testing is negative in a patient who is strongly
suspected of having COVID-19 infection, the patient
should be resampled, with a sampling time interval of
at least 1 day and specimens collected from multiple
respiratory-tract sites (nose, sputum, endotracheal aspi-
rate). Additional specimens, such as blood, urine and
stool, may be collected to monitor the presence of virus
and the shedding of virus from different body com-
partments. When qRT-PCR analysis is negative for two
consecutive tests, COVID-19 infection can be ruled out.
A contact is defined as a person involved in any of the
Providing direct care for COVID-19 patients without
using proper personal protective equipment (PPE)
Being in the same close environment as a COVID-19
patient (including sharing workplace, classroom or
household, or attending the same gathering)
Traveling in close proximity (within 12 meters) to a
COVID-19 patient in any kind of conveyance
Copyright ©2020 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2020.
ISUOG Interim Guidance 3
The WHO has provided guidance on the rational use of
PPE for COVID-19. When conducting aerosol-generating
procedures (e.g. tracheal intubation, non-invasive ventila-
tion, cardiopulmonary resuscitation, manual ventilation
before intubation), healthcare workers are advised to
use respirators (e.g. N95, FFP2 or equivalent standard)
with their PPE20,21. CDC additionally considers proce-
dures that are likely to induce coughing (e.g. sputum
induction, collection of nasopharyngeal swabs and suc-
tioning) as aerosol-generating procedures and CDC guid-
ance includes the option of using a powered air-purifying
respirator (PAPR).
Chest imaging, especially CT scan, is essential for eval-
uation of the clinical condition of a pregnant woman
with COVID-19 infection22 24. Fetal growth restric-
tion (FGR), microcephaly and intellectual disability
are the most common adverse effects from high-dose
(>610 mGy) radiation exposure25 27. According to data
from the American College of Radiology and Ameri-
can College of Obstetricians and Gynecologists, when a
pregnant woman undergoes a single chest X-ray examina-
tion, the radiation dose to the fetus is 0.00050.01 mGy,
which is negligible, while the radiation dose to the fetus is
0.010.66 mGy from a single chest CT or CT pulmonary
Chest CT scanning has high sensitivity for diagnosis
of COVID-1924. In a pregnant woman with suspected
COVID-19 infection, a chest CT scan may be consid-
ered as a primary tool for the detection of COVID-19
in epidemic areas24. Informed consent should be acquired
(shared decision-making) and a radiation shield be applied
over the gravid uterus.
Place of care
Suspected, probable and confirmed cases of COVID-19
infection should be managed initially by designated
tertiary hospitals with effective isolation facilities and
protection equipment. Suspected/probable cases should
be treated in isolation and confirmed cases should be
managed in a negative-pressure isolation room. A con-
firmed case that is critically ill should be admitted to a
negative-pressure isolation room in an ICU31. Designated
hospitals should set up a dedicated negative-pressure oper-
ating room and a neonatal isolation ward. All attending
medical staff should don PPE (respirator, goggle, face pro-
tective shield, surgical gown and gloves) when providing
care for confirmed cases of COVID-19 infection32.
However, in areas with widespread local transmission
of the disease, health services may be unable to provide
such levels of care to all suspected, probable or confirmed
cases. Pregnant women with a mild clinical presentation
may not initially require hospital admission and home
confinement can be considered, provided that this is pos-
sible logistically and that monitoring of the woman’s
condition can be ensured33. If negative-pressure isolation
rooms are not available, patients should be isolated in sin-
gle rooms, or grouped together once COVID-19 infection
has been confirmed.
For transfer of confirmed cases, the attending medi-
cal team should don PPE and keep themselves and their
patient a minimum distance of 12 meters from any indi-
viduals without PPE.
Suspected/probable cases
a. General treatment: maintain fluid and electrolyte bal-
ance; symptomatic treatment, such as antipyrexic,
antidiarrheal medicines.
b. (1) Surveillance: close and vigilant monitoring of
vital signs and oxygen saturation level to mini-
mize maternal hypoxia; conduct arterial blood-gas
analysis; repeat chest imaging (when indicated); reg-
ular evaluation of complete blood count, renal- and
liver-function testing and coagulation testing. (2) Fetal
monitoring: undertake cardiotocography (CTG) for
fetal heart rate (FHR) monitoring when pregnancy
is 26 or 28 weeks of gestation (depending on
local practice), and ultrasound assessment of fetal
growth and amniotic fluid volume with umbilical
artery Doppler if necessary. Note that monitoring
devices and ultrasound equipment should be disin-
fected adequately before further use. (3) The preg-
nancy should be managed according to the clinical
and ultrasound findings, regardless of the timing
of infection during pregnancy. All visits for obstet-
ric emergencies should be offered in agreement with
current local guidelines. All routine follow-up appoint-
ments should be postponed by 14 days or until positive
test results (or two consecutive negative test results) are
Confirmed cases
a. Non-severe disease. (1) The approach to main-
taining fluid and electrolyte balance, symptomatic
treatment and surveillance is the same as for sus-
pected/probable cases. (2) Currently there is no proven
antiviral treatment for COVID-19 patients, although
antiretroviral drugs are being trialed therapeutically
on patients with severe symptoms34,35. If antiviral
treatment is to be considered, this should be done
following careful discussion with virologists; preg-
nant patients should be counseled thoroughly on the
potential adverse effects of antiviral treatment for
the patient herself as well as on the risk of FGR.
(3) Monitoring for bacterial infection (blood culture,
mid-stream or catheterized-specimen urine microscopy
and culture) should be done, with timely use of appro-
priate antibiotics when there is evidence of secondary
bacterial infection. When there is no clear evidence
Copyright ©2020 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2020.
4ISUOG Interim Guidance
of secondary bacterial infection, empirical or inap-
propriate use of antibiotics should be avoided. (4)
Fetal monitoring: undertake CTG for FHR monitor-
ing when pregnancy is 26 –28 weeks of gestation,
and ultrasound assessment of fetal growth and amni-
otic fluid volume with umbilical artery Doppler if
b. Severe and critical disease. (1) The degree of severity
of COVID-19 pneumonia is defined by the Infec-
tious Diseases Society of America/American Thoracic
Society guidelines for community-acquired pneumo-
nia (Appendix 1)36. (2) Severe pneumonia is asso-
ciated with a high maternal and perinatal mortal-
ity rate, therefore, aggressive treatment is required,
including supporting measures with hydration, oxy-
gen therapy and chest physiotherapy. The case should
be managed in a negative-pressure isolation room
in the ICU, preferably with the woman in a left
lateral position, with the support of a multidisci-
plinary team (obstetricians, maternalfetal-medicine
subspecialists, intensivists, obstetric anesthetists, mid-
wives, virologists, microbiologists, neonatologists,
infectious-disease specialists)37. (3) Antibacterial treat-
ment: appropriate antibiotic treatment in combination
with antiviral treatment should be used promptly when
there is suspected or confirmed secondary bacterial
infection, following discussion with microbiologists.
(4) Blood-pressure monitoring and fluid-balance man-
agement: in patients without septic shock, conservative
fluid management measures should be undertaken38;
in patients with septic shock, fluid resuscitation and
inotropes are required to maintain an average arte-
rial pressure 60 mmHg (1 mmHg =0.133 kPa) and
a lactate level <2 mmol/L39. (5) Oxygen therapy:
supplemental oxygen should be used to maintain oxy-
gen saturation 95%40,41; oxygen should be given
promptly to patients with hypoxemia and/or shock42,
and method of ventilation should be according to
the patient’s condition and following guidance from
the intensivists and obstetric anesthetists. (6) Fetal
monitoring: if appropriate, CTG for FHR mon-
itoring should be undertaken when pregnancy is
2628 weeks of gestation, and ultrasound assess-
ment of fetal growth and amniotic fluid volume with
umbilical artery Doppler should be performed, if nec-
essary, once the patient is stabilized. (7) Medically
indicated preterm delivery should be considered by
the multidisciplinary team on a case-by-case basis.
Currently, there are limited data on the impact on the fetus
of maternal COVID-19 infection. It has been reported
that viral pneumonia in pregnant women is associated
with an increased risk of preterm birth, FGR and peri-
natal mortality43. Based on nationwide population-based
data, it was demonstrated that pregnant women with
other viral pneumonias (n=1462) had an increased risk
of preterm birth, FGR and having a newborn with low
birth weight and Apgar score <7at5min,comparedwith
those without pneumonia (n=7310)44. In 2004, a case
series of 12 pregnant women with SARS-CoV in Hong
Kong, China, reported three maternal deaths, that four
of seven patients who presented in the first trimester had
spontaneous miscarriage, four of five patients who pre-
sented after 24 weeks had preterm birth and two mothers
recovered without delivery but their ongoing pregnan-
cies were complicated by FGR9. Pregnant women with
suspected/probable COVID-19 infection, or those with
confirmed infection who are asymptomatic or recovering
from mild illness, should be monitored with 24-weekly
ultrasound assessment of fetal growth and amniotic fluid
volume, with umbilical artery Doppler if necessary45.At
present, it is uncertain whether there is a risk of ver-
tical mother-to-baby transmission. In a study by Chen
et al.46, of nine pregnant women with COVID-19 in the
third trimester, amniotic fluid, cord blood and neonatal
throat-swab samples collected from six patients tested
negative for COVID-19, suggesting there was no evidence
of intrauterine infection caused by vertical transmission
in women who developed COVID-19 pneumonia in late
pregnancy. However, there are currently no data on peri-
natal outcome when the infection is acquired in the first
and early second trimester of pregnancy, and these preg-
nancies should be monitored carefully after recovery.
Following ultrasound examination, ensure surfaces of
transducers are cleaned and disinfected according to man-
ufacturer specifications, taking note of the recommended
‘wet time’ for wiping transducers and other surfaces with
disinfection agents47. Consider using protective covers for
probes and cables, especially when there are infected skin
lesions or when a transvaginal scan is necessary. In the
case of high infectivity, a ‘deep clean’ of the equipment is
necessary. A bedside scan is preferred; if the patient needs
to be scanned in the clinic, this should be done at the end
of the list, as the room and equipment will subsequently
require a deep clean. Reprocessing of the probes should
be documented for traceability47.
1. COVID-19 infection itself is not an indication for
delivery, unless there is a need to improve maternal
oxygenation. For suspected, probable and confirmed
cases of COVID-19 infection, delivery should be con-
ducted in a negative-pressure isolation room. The
timing and mode of delivery should be individualized,
dependent mainly on the clinical status of the patient,
gestational age and fetal condition48.Intheeventthat
an infected woman has spontaneous onset of labor
with optimal progress, she can be allowed to deliver
vaginally. Shortening the second stage by operative
vaginal delivery can be considered, as active pushing
while wearing a surgical mask may be difficult for
Copyright ©2020 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2020.
ISUOG Interim Guidance 5
the woman to achieve49. With respect to a pregnant
woman without a diagnosis of COVID-19 infection,
but who might be a silent carrier of the virus, we
urge caution regarding the practice of active push-
ing while wearing a surgical mask, as it is unclear if
there is an increased risk of exposure to any health-
care professional attending the delivery without PPE,
because forceful exhalation may significantly reduce
the effectiveness of a mask in preventing the spread
of the virus by respiratory droplets49. Induction of
labor can be considered when the cervix is favorable,
but there should be a low threshold to expedite the
delivery when there is fetal distress, poor progress in
labor and/or deterioration in maternal condition. Sep-
tic shock, acute organ failure or fetal distress should
prompt emergency Cesarean delivery (or termination,
if legal, before fetal viability)45. For the protection
of the medical team, water birth should be avoided.
Both regional anesthesia and general anesthesia can
be considered, depending on the clinical condition of
the patient and after consultation with the obstetric
2. For preterm cases requiring delivery, we urge caution
regarding the use of antenatal steroids (dexametha-
sone or betamethasone) for fetal lung maturation
in a critically ill patient, because this can poten-
tially worsen the clinical condition50 and the admini-
stration of antenatal steroids would delay the
delivery that is necessary for management of the
patient. The use of antenatal steroids should be
considered in discussion with infectious-disease spe-
cialists, maternalfetal-medicine subspecialists and
neonatologists37,51. In the case of an infected woman
presenting with spontaneous preterm labor, tocolysis
should not be used in an attempt to delay delivery in
order to administer antenatal steroids.
3. Miscarried embryos/fetuses and placentae of
COVID-19-infected pregnant women should be
treated as infectious tissues and they should be
disposed of appropriately; if possible, testing of
these tissues for COVID-19 by qRT-PCR should be
4. Regarding neonatal management of suspected, proba-
ble and confirmed cases of maternal COVID-19 infec-
tion, the umbilical cord should be clamped promptly
and the neonate should be transferred to the resusci-
tation area for assessment by the attending pediatric
team. There is insufficient evidence regarding whether
delayed cord clamping increases the risk of infec-
tion to the newborn via direct contact51.Inunitsin
which delayed cord clamping is recommended, clini-
cians should consider carefully whether this practice
should be continued. There is currently insufficient
evidence regarding the safety of breastfeeding and the
need for motherbaby separation46,52.Ifthemother
is severely or critically ill, separation appears to be
the best option, with attempts to express breastmilk
in order to maintain milk production. Precautions
should be taken when cleaning the breast pumps. If
the patient is asymptomatic or mildly affected, breast-
feeding and colocation (also called rooming-in) can
be considered by the mother in coordination with
healthcare providers, or may be necessary if facility
limitations prevent motherbaby separation. Since the
main concern is that the virus may be transmitted by
respiratory droplets rather than breastmilk, breast-
feeding mothers should ensure to wash their hands
and wear a three-ply surgical mask before touching
the baby. In case of rooming-in, the baby’s cot should
be kept at least 2 meters from the mother’s bed, and a
physical barrier such as a curtain may be used53,54.
5. The need to separate mothers with COVID-19 infec-
tion from their newborns, with the consequence that
they are unable to breastfeed directly, may impede
early bonding as well as establishment of lactation55.
These factors will inevitably cause additional stress
for mothers in the postpartum period. As well as car-
ing for their physical wellbeing, medical teams should
consider the mental wellbeing of these mothers, show-
ing appropriate concern and providing support when
Fever is common in COVID-19-infected patients. Previ-
ous data have demonstrated that maternal fever in early
pregnancy can cause congenital structural abnormali-
ties involving the neural tube, heart, kidney and other
organs56 59. However, a recent study60 , including 80 321
pregnant women, reported that the rate of fever in early
pregnancy was 10%, while the incidence of fetal mal-
formation in this group was 3.7%. Among the 77 344
viable pregnancies with data collected at 1629 weeks of
gestation, in the 8321 pregnant women with a reported
temperature >38C lasting 1 –4 days in early pregnancy,
compared to those without a fever in early pregnancy, the
overall risk of fetal malformation was not increased (odds
ratio =0.99 (95% CI, 0.88 –1.12))60. Previous studies
have reported no evidence of congenital infection with
SARS-CoV61, and currently there are no data on the risk
of congenital malformation when COVID-19 infection
is acquired during the first or early second trimester
of pregnancy. Nonetheless, a detailed morphology scan
at 1824 weeks of gestation is indicated for pregnant
women with suspected, probable or confirmed COVID-19
Currently, there are no effective drugs or vaccines to pre-
vent COVID-19. Therefore, personal protection should
be considered in order to minimize the risk of contracting
the virus62.
Patients and healthcare providers
a. Maintain good personal hygiene: consciously avoid
close contact with others during the COVID-19
Copyright ©2020 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2020.
6ISUOG Interim Guidance
epidemic period, reduce participation in any gathering
in which a distance of at least 1 meter between indi-
viduals cannot be maintained, pay attention to hand
washing and use hand sanitizer (with 70% alcohol
concentration63) frequently.
b. Some national health authorities and some hospital
systems recommend wearing a three-ply surgical mask
when visiting a hospital or other high-risk area.
c. Seek medical assistance promptly for timely diagnosis
and treatment when experiencing symptoms such as
fever and cough.
Healthcare providers
d. Consider providing educational information
(brochures, posters) in waiting areas.
e. Set up triage plans for screening. In units in which
triage areas have been set up, staff should have appro-
priate protective equipment and be strictly compliant
with hand hygiene.
f. All pregnant patients who present to the hospital and
for outpatient visits should be assessed and screened
for symptoms and risk factors based on travel history,
occupation, significant contact and cluster (TOCC)
(Appendix 2).
g. Pregnant patients with known TOCC risk factors and
those with mild or asymptomatic COVID-19 infection
should delay antenatal visit and routine ultrasound
assessment by 14 days.
h. Consider reducing the number of visitors to the
i. In units in which routine group-B streptococcus (GBS)
screening is practiced, acquisition of vaginal and/or
anal swabs should be delayed by 14 days in preg-
nant women with TOCC risk factors or should
be performed only after a suspected/probable case
tests negative or after recovery in a confirmed case.
Intrapartum prophylactic antibiotic cover for women
with ante- or intrapartum risk factors for GBS is an
j. On presentation to triage areas, pregnant patients with
TOCC risk factors should be placed in an isolation
room for further assessment.
k. Medical staff who are caring for suspected, probable
or confirmed cases of COVID-19 patients should be
monitored closely for fever or other signs of infection
and should not be working if they have any COVID-19
symptoms. Common symptoms at onset of illness
include fever, dry cough, myalgia, fatigue, dyspnea and
anorexia. Some national health authorities and hos-
pital systems recommend that medical staff assigned
to care for suspected, probable or confirmed cases
of COVID-19 patients should minimize contact with
other patients and colleagues, with the aim of reducing
the risk of exposure and potential transmission.
l. Medical staff who have been exposed unexpectedly,
while without PPE, to a COVID-19-infected preg-
nant patient, should be quarantined or self-isolate for
14 days.
m. Pregnant healthcare professionals should follow
risk-assessment and infection-control guidelines fol-
lowing exposure to patients with suspected, probable
or confirmed COVID-19.
1. Pregnant women with confirmed COVID-19 infec-
tion should be managed by designated tertiary hos-
pitals, and they should be informed of the risk of
adverse pregnancy outcome.
2. Negative-pressure isolation rooms should be set up
for safe labor and delivery and neonatal care.
3. During the COVID-19 epidemic period, a detailed
history regarding recent travel, occupation, signif-
icant contact and cluster (i.e. TOCC) and clinical
manifestations should be acquired routinely from all
pregnant women attending for routine care.
4. Chest imaging, especially CT scan, should be
included in the work-up of pregnant women with sus-
pected, probable or confirmed COVID-19 infection.
5. Suspected/probable cases should be treated in iso-
lation and confirmed cases should be managed in
a negative-pressure isolation room. A woman with
confirmed infection who is critically ill should be
admitted to a negative-pressure isolation room in the
6. Antenatal examination and delivery of pregnant
women infected with COVID-19 should be carried
out in a negative-pressure isolation room on the
labor ward. Human traffic around this room should
be limited when it is occupied by an infected patient.
7. All medical staff involved in management of infected
women should don PPE as required.
8. Management of COVID-19-infected pregnant
women should be undertaken by a multidisciplinary
team (obstetricians, maternalfetal-medicine sub-
specialists, intensivists, obstetric anesthetists, mid-
wives, virologists, microbiologists, neonatologists,
infectious-disease specialists).
9. Timing and mode of delivery should be individual-
ized, dependent mainly on the clinical status of the
patient, gestational age and fetal condition.
10. Both regional anesthesia and general anesthesia can
be considered, depending on the clinical condition of
the patient and after consultation with the obstetric
11. At present, limited data suggest that there is no
evidence of vertical mother-to-baby transmission in
women who develop COVID-19 infection in late
12. There is currently insufficient evidence regarding the
safety of breastfeeding and the need for motherbaby
separation. If the mother is severely or critically ill,
separation appears the best option, with attempts to
express breastmilk in order to maintain milk pro-
duction. If the patient is asymptomatic or mildly
affected, breastfeeding and colocation (rooming-in)
Copyright ©2020 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2020.
ISUOG Interim Guidance 7
can be considered by the mother in coordination
with healthcare providers.
13. Healthcare professionals engaged in obstetric care
and those who perform obstetric ultrasound exam-
inations should be trained and fitted appropriately
for respirators and/or PAPR.
14. Following an ultrasound scan of a suspected, prob-
able or confirmed COVID-19-infected pregnant
patient, surfaces of transducers should be cleaned
and disinfected according to manufacturer specifica-
tions, taking note of the recommended ‘wet time’ for
wiping transducers and other surfaces with disinfec-
tion agents.
This Interim Guidance was produced by:
L. C. Poon, Department of Obstetrics and Gynaecology,
The Chinese University of Hong Kong, Hong Kong SAR
H. Yang, Department of Obstetrics and Gynecology,
Peking University First Hospital, Beijing, China
J. C. S. Lee, Department of Obstetrics and Gynaecology,
KK Women’s and Children’s Hospital, Singapore
J. A. Copel, Department of Obstetrics, Gynecology &
Reproductive Sciences, Yale School of Medicine, New
Haven, CT, USA
T. Y. Leung, Department of Obstetrics and Gynaecology,
The Chinese University of Hong Kong, Hong Kong SAR
Y. Zhang, Department of Obstetrics and Gynaecology,
Zhongnan Hospital of Wuhan University, Wuhan, China
D. Chen, Department of Obstetrics and Gynaecology,
The Third Affiliated Hospital of Guangzhou Medical
University, Guangzhou, China
F. Prefumo, Department of Clinical and Experimental
Sciences, University of Brescia, Brescia, Italy
This Interim Guidance should be cited as: Poon LC, Yang
H, Lee JCS, Copel JA, Leung TY, Zhang Y, Chen D,
Prefumo F. ISUOG Interim Guidance on 2019 novel coro-
navirus infection during pregnancy and puerperium: infor-
mation for healthcare professionals. Ultrasound Obstet
Gynecol 2020. DOI: 10.1002/uog.22013.
1. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X,
ChengZ,YuT,XiaJ,WeiY,WuW,et al. Clinical features of patients infected with
2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497– 506.
2. World Health Organization. Novel coronavirus - China. Disease outbreak news:
Update. 12 January 2020.
coronavirus-china/en/ [Accessed 7 March 2020].
3. Coronavirus COVID-19 Global Cases by the Center for Systems Science and
Engineering (CSSE) at Johns Hopkins University.
4. Su S, Wong G, Shi W, Liu J, Lai ACK, Zhou J, Liu W, Bi Y, Gao GF. Epidemiology,
genetic recombination, and pathogenesis of coronaviruses. Trends Microbiol 2016;
24: 490– 502.
5. Ksiazek TG, Erdman D, Goldsmith CS, Zaki SR, Peret T, Emery S, Tong S, Urbani C,
Comer JA, Lim W, Rollin PE, Dowell SF, Ling AE, Humphrey CD, Shieh WJ, et al.;
SARS Working Group. A novel coronavirus associated with severe acute respiratory
syndrome. NEnglJMed2003; 348: 1953 –1966.
6. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RA. Isolation
of a novel coronavirus from a man with pneumonia in Saudi Arabia. NEnglJMed
2012; 367: 1814– 1820.
7. World Health Organization. Emergencies preparedness, response. Summary of prob-
able SARS cases with onset of illness from 1 November 2002 to 31 July 2003.
8. World Health Organization. Middle East respiratory syndrome coronavirus
(MERS-CoV). MERS Monthly Summary, November 2019.
9. Wong SF, Chow KM, Leung TN, Ng WF, Ng TK, Shek CC, Ng PC, Lam PW,
Ho LC, To WW, Lai ST, Yan WW, Tan PY. Pregnancy and perinatal outcomes of
women with severe acute respiratory syndrome. Am J Obstet Gynecol 2004; 191:
292– 297.
10. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, Wang W, Song H, Huang B, Zhu N, Bi Y,
Ma X, Zhan F, Wang L, Hu T, et al. Genomic characterisation and epidemiology of
2019 novel coronavirus: implications for virus origins and receptor binding. Lancet
2020; 395: 565– 574.
11. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19).
16-24 February 2020.
who-china-joint-mission-on-covid-19-final-report.pdf [Accessed 9 March 2020].
12. WHO Director-General’s opening remarks at the media briefing on COVID-1
- 3 March 2020.
13. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y,
Zhao Y, Li Y, Wang X, Peng Z. Clinical characteristics of 138 hospitalized patients
with 2019 novel coronavirus infected pneumonia in Wuhan, China. JAMA 2020.
DOI: 10.1001/jama.2020.1585.
14. Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, Liu L, Shan H, Lei C, Hui DSC, Du B,
Li L, Zeng G, Yuen K, Chen R, et al. Clinical characteristics of 2019 novel coronavirus
infection in China. medRxiv 2020.
15. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC,
Du B, Li LJ, Zeng G, Yuen KY, Chen RC, et al., for the China Medical Treatment
Expert Group for Covid-19. Clinical Characteristics of CoronavirusDisease 2019 in
China. NEnglJMed2020. DOI: 10.1056/NEJMoa2002032.
16. Siston AM, Rasmussen SA, Honein MA, Fry AM, Seib K, Callaghan WM, Louie J,
Doyle TJ, Crockett M, Lynfield R, Moore Z, Wiedeman C, Anand M, Tabony L,
Nielsen CF, et al.; Pandemic H1N1 Influenza in Pregnancy Working Group. Pan-
demic 2009 influenza A(H1N1) virus illness among pregnant women in the United
States. JAMA 2010; 303: 1517– 1525.
17. Alfaraj SH, Al-Tawfiq JA, Memish ZA. Middle East respiratory syndrome coron-
avirus (MERS-CoV) infection during pregnancy: report of two cases & review of the
literature. J Microbiol Immunol Infect 2019; 52: 501– 503.
18. WHO. Global surveillance for COVID-19 disease caused by human infection with the
2019 novel coronavirus. Interim guidance. 27 February 2020.
(2019-ncov) [Accessed 7 March 2020].
19. European Centre for Disease Prevention and Control. Daily risk assessment on
COVID-19, 7 March 2020.
novel-coronavirus-situation [Accessed 8 March 2020].
20. WHO. Rational use of protective equipment for coronavirus disease 2019
(COVID-19). Interim guidance. 27 February 2020.
[Accessed 8 March 2020].
21. Centers for Disease Control and Prevention. Interim Infection Prevention and Con-
trol Recommendations for Patients with Confirmed Coronavirus Disease 2019
(COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.
21 February 2020.
control-recommendations.html [Accessed 8 March 2020].
22. Li X, Xia L. Coronavirus Disease 2019 (COVID-19): Role of Chest CT in Diagnosis
and Management. AJR Am J Roentgenol 2020. DOI: 10.2214/AJR.20.22954.
23. Zhao W, Zhong Z, Xie X, Yu Q, Liu J. Relation Between Chest CT Findings and
Clinical Conditions of Coronavirus Disease (COVID-19) Pneumonia: A Multicenter
Study. AJR Am J Roentgenol 2020. DOI: 10.2214/AJR.20.22976.
24. Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, Tao Q, Sun Z, Xia L. Correlation of
chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a
report of 1014 cases. Radiology 2020. DOI:10.1148/radiol.2020200642.
25. Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant
patient for nonobstetric conditions: algorithms and radiation dose considerations.
Radiographics 2007; 27: 1705– 1722.
26. National Library of Medicine. Gadopentetate. In: Drugs and Lactation Database
DOCNO+519 [Accessed 7 March 2020].
27. Miller RW. Discussion: severe mental retardation and cancer among atomic bomb
survivors exposed in utero. Teratology 1999; 59: 234– 235.
28. Committee Opinion No. 723: Guidelines for diagnostic imaging during pregnancy
and lactation. Obstet Gynecol 2017; 130: e210– e216.
29. American College of Radiology. ACR-SPR practice parameter for imaging pregnant
or potentially pregnant adolescents and women with ionizing radiation. Revised
30. Tremblay E, Th ´
erasse E, Thomassin-Naggara I, Trop I. Quality initiatives: guidelines
for use of medical imaging during pregnancy and lactation. Radiographics 2012; 32:
897– 911.
31. The Lancet. Emerging understandings of 2019-nCoV. Lancet 2020; 395: 311.
32. Maxwell C, McGeer A, Tai KFY, Sermer M. No. 225 - Management guidelines for
obstetric patients and neonates born to mothers with suspected or probable severe
acute respiratory syndrome (SARS). J Obstet Gynaecol Can 2017; 39: e130– e137.
33. Centers for Disease Control. Interim Clinical Guidance for Management of
Patients with Confirmed Coronavirus Disease (COVID-19).
Copyright ©2020 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2020.
8ISUOG Interim Guidance
coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html [Accessed
8th March 2020].
34. Boseley S. China trials anti-HIV drug on coronavirus patients. The Guardian [cited 15
February 2020].
35. NIH clinical trial of remdesivir to treat COVID-19 begins. 25 February 2020.
covid-19-begins [Accessed 9 March 2020].
36. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA,
Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo
MI, Whitney CG; on behalf of the American Thoracic Society and Infectious Diseases
Society of America. Diagnosis and Treatment of Adults with Community-acquired
Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society
and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:
e45– e67.
37. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease
2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet
Gynecol 2020. DOI: 10.1016/j.ajog.2020.02.017.
38. Schultz MJ, Dunser MW, Dondorp AM, Adhikari NKJ, Iyer S, Kwizera A, Lubell Y,
Papali A, Pisani L, Riviello ED, Angus DC, Azevedo LC, Baker T, Diaz JV, Festic E,
et al. Current challenges in the management of sepsis in ICUs in resource-poor settings
and suggestions for the future. Intensive Care Med 2017; 43: 612– 624.
39. Plante LA, Pacheco LD, Louis JM. SMFM Consult Series #47: Sepsis during preg-
nancy and the puerperium. Am J Obstet Gynecol 2019; 220: B2– B10.
40. Røsjø H, Varpula M, Hagve TA, Karlsson S, Ruokonen E, Pettila V, Omland T;
FINNESEPSIS Study Group. Circulating high sensitivity troponin T in severe sepsis
and septic shock: distribution, associated factors, and relation to outcome. Intensive
Care Med 2011; 37: 77– 85.
41. Bhatia PK, Biyani G, Mohammed S, Sethi P, Bihani P. Acute respiratory failure
and mechanical ventilation in pregnant patient: A narrative review of literature.
J Anaesthesiol Clin Pharmacol 2016; 32: 431– 439.
42. World Health Organization. Clinical management of severe acute respiratory
infection when novel coronavirus (nCoV) infection is suspected. Interim guidance.
28 January 2020.
suspected [Accessed 7 March 2020].
43. Madinger NE, Greenspoon JS, Ellrodt AG. Pneumonia during pregnancy: has mod-
ern technology improved maternal and fetal outcome? Am J Obstet Gynecol 1989;
161: 657– 662.
44. Chen YH, Keller J, Wang IT, Lin CC, Lin HC. Pneumonia and pregnancy outcomes:
a nationwide population-based study. Am J Obstet Gynecol 2012; 207: 288.e1– 7.
45. Favre G, Pomar L, Qi X, Nielsen-Saines K, Musso D, Baud D. Guidelines for
pregnant women with suspected SARS-CoV-2 infection. Lancet Infect Dis 2020.
46. ChenH,GuoJ,WangC,LuoF,YuX,ZhangW,LiJ,ZhaoD,XuD,GongQ,LiaoJ,
Yang H, Hou W, Zhang Y. Clinical characteristics and intrauterine vertical transmis-
sion potential of COVID-19 infection in nine pregnant women: a retrospective review
of medical records. Lancet 2020.
47. Basseal JM, Westerway SC, Juraja M, van de Mortel T, McAuley TE, Rippey J,
Meyer-Henry S, Maloney S, Ayers A, Jain S, Mizia K, Twentyman, D. Guidelines for
reprocessing ultrasound transducers. AJUM 2017; 20: 30– 40.
48. Qi H, Chen D, Feng L, Zou L, Li J. Obstetric considerations on delivery issues for
pregnant women with COVID-19 infection. Chin J Obstet Gynecol 2020; 55: E001.
49. Yang H, Wang C, Poon LC. Novel coronavirus infection and pregnancy. Ultrasound
Obstet Gynecol 2020. DOI:10.1002/uog.22006.
50. Rodrigo C, Leonardi-Bee J, Nguyen-Van-Tam J, Lim WS. Corticosteroids as adjunc-
tive therapy in the treatment of influenza. Cochrane Database Syst Rev 2016; 3:
51. Mullins E, Evans D, Viner R, O’Brien, P, Morris E. Coronavirus in pregnancy and
delivery: rapid review and expert consensus. medRxiv 8 March 2020.
52. Zhu Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, Xia S, Zhou W. Clinical
analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr
2020; 9. DOI: 10.21037/tp.2020.02.06.
53. Centers for Disease Control. Interim Considerations for Infection Prevention and
Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Health-
care Settings.
healthcare-guidance.html#anchor_;1582067966715. [Accessed 8 March 2020].
54. American College of Obstetricians and Gynecologists. Practice Advisory: Novel
Coronavirus 2019 (COVID-19).
IsMobileSet=false [Accessed 8 March 2020].
55. Chua MSQ, Lee JCS, Sulaiman S, Tan HK. From the frontlines of
COVID-19 – How prepared are we as obstetricians: a commentary. BJOG 2020.
56. Yin Z, Xu W, Xu C, Zhang S, Zheng Y, Wang W, Zhou B. A population-based
case-control study of risk factors for neural tube defects in Shenyang, China. Childs
Nerv Syst 2011; 27: 149– 154.
57. Shaw GM, Todoroff K, Velie EM, Lammer EJ. Maternal illness, including fever and
medication use as risk factors for neural tube defects. Teratology 1998; 57:1–7.
58. Oster ME, Riehle-Colarusso T, Alverson CJ, Correa A. Associations between mater-
nal fever and influenza and congenital heart defects. JPediatr2011; 158: 990 –995.
59. Abe K, Honein MA, Moore CA. Maternal febrile illnesses, medication use, and the
risk of congenital renal anomalies. Birth Defects Res A Clin Mol Teratol 2003; 67:
911– 918.
60. Sass L, Urhoj SK, Kjærgaard J, Dreier JW, Strandberg-Larsen K, Nybo Andersen
AM. Fever in pregnancy and the risk of congenital malformations: a cohort study.
BMC Pregnancy Childbirth 2017; 17: 413.
61. Shek CC, Ng PC, Fung GP, Cheng FW, Chan PK, Peiris MJ, Lee KH, Wong SF,
Cheung HM, Li AM, Hon EK, Yeung CK, Chow CB, Tam JS, Chiu MC, Fok TF.
Infants born to mothers with severe acute respiratory syndrome. Pediatrics 2003;
112: e254.
62. Maternal and Fetal Experts Committee, Chinese Physician Society of Obstetrics
and Gynecology, Chinese Medical Doctor Association; Obstetric Subgroup, Society
of Obstetrics and Gynecology, Chinese Medical Association; Society of Perina-
tal Medicine, Chinese Medical Association; Editorial Board of Chinese Journal of
Perinatal Medicine. Proposed management of COVID-19 during pregnancy and
puerperium. Chin J Perinat Med 2020; 23: 73– 79.
63. WHO. Infection prevention and control during health care when novel coro-
navirus (nCoV) infection is suspected. Interim guidance. 25 January 2020.
[Accessed 7 March 2020].
64. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection
Control Practices Advisory Committee. Guideline for Isolation Precautions: Prevent-
ing Transmission of Infectious Agents in Healthcare Settings (2007). https://www.
Appendix 1 2007 Infectious Diseases Society of America/American Thoracic Society criteria for defining severe
community-acquired pneumonia. Validated definition includes either one major criterion or three or more minor
Copyright ©2020 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2020.
ISUOG Interim Guidance 9
Appendix 2 Example of symptoms and TOCC (travel history, occupation, significant contact and cluster) checklist
Droplet precautions: put a mask on the patient; single room; healthcare worker uses PPE appropriately, including a
mask, upon entry to room64.
Contact precautions: single room; healthcare worker uses PPE appropriately upon entry to room, including gloves and
gown; use disposable equipment64.
Airborne precautions: put a mask on the patient; negative-pressure isolation room; healthcare worker uses PPE
appropriately upon entry to room, including wearing a fit-test approved respirator, gloves, gowns, face and eye
protection; negative-pressure isolation room; restrict susceptible healthcare workers from entering the room; use
disposable equipment64.
Copyright ©2020 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2020.
... La contribución de los científicos españoles, (4,5) y de otros, a nivel mundial, (6,7,8) ha devenido fomento de la lactancia materna para la protección y recuperación de niños con la COVID-19; y para la elaboración de guías para el manejo nutricional de niños de madres enfermas y sospechosas de infección con SARCoV-2 de varios países y territorios del mundo. ...
... (9) Por esta razón, varias organizaciones científicas del mundo están a favor de la lactancia materna en el manejo de casos con infección por SARCoV-2, siempre que el estado de la madre y el neonato lo permitan. (6,7,8,10) Basado en los resultados científicos del momento y las experiencias prácticas acumuladas, la Organización Mundial para la Salud y la Academy of Breastfeeding Medicine recomiendan mantener la lactancia materna en la alimentación de los recién nacidos y lactantes, tanto para casos de madres con infección confirmada a SARCoV-2 como probable, siempre que se mantengan las medidas para la prevención de infección por microorganismos transmitidos por gotas y por contacto. (4,8) Las regulaciones sugeridas para evitar la transmisión con la COVID-19 durante la lactación incluyen el uso de mascarillas, lavado correcto de las manos antes y después de la toma, y la limpieza de la piel de la mama y de las superficies que puedan estar en contacto. ...
... En la actualidad, la mayoría de los países tiene en el protocolo de actuación recomendaciones a favor de la lactancia materna. (4,6,8,11) Este pronunciamiento ha servido de referente para adoptar decisiones con respecto a la alimentación del niño pequeño en tiempos de la COVID-19. ...
... COVID-19 may disproportionately impact the elderly and those with cardiologic, pulmonary, renal, and metabolic comorbidities (5). This is also manifest in pregnancies where it is a well-documented fact that pregnancy-related alterations in maternal physiology make pregnant women more susceptible to a more severe course of pneumonia, resulting in higher maternal and fetal morbidity and mortality (6,7). This is because the maternal respiratory system undergoes various physiological alterations throughout pregnancy. ...
Full-text available
Background: COVID-19 infection is a contemporary global concern with serious ramifications. This disease is caused by a virus belonging to the Coronaviridae family named SARS-CoV-2. Immunologic and physiologic changes during pregnancy make pregnant women more susceptible to viral infection, especially COVID-19. Objectives: The present study aimed to identify the clinical manifestations, radiologic findings, indications for cesarean delivery, underlying conditions, and the critical outcome of mothers and newborns regarding COVID-19 women who had cesarean sections and terminated pregnancies. Methods: This cross-sectional study was conducted on the mortality and morbidity rates of 98 women with terminated pregnancies infected with COVID-19 at the time of their cesarean delivery. The demographic, clinical, and pregnancy data were collected from Razi Teaching Hospital between March 2020 and March 2021 and analyzed using SPSS version 24. Results: The mean age was 31.31 ± 7.16, and the mean gestational age was 36.45 ± 3.334 weeks. The most prevalent cause of cesarean section was fetal distress (28%), followed by preeclampsia and meconium aspiration. The most common symptoms were sore throat, cough, fever, nausea, diarrhea, and weakness; moreover, hypothyroidism and diabetes mellitus were the most predominant underlying diseases. The mean duration for hospitalization was 5.21 ± 4.584 days, the maternal death rate was 5.1%, and the neonatal death rate was 2%. Conclusions: The majority of women infected with COVID-19 had cesarean sections and terminated pregnancies in the third trimester. This highlights the need for better care and education for mothers in this period. The body mass index (BMI) level and obesity are strongly associated with COVID-19 severity. Furthermore, healthcare workers should pay more attention to underlying diseases during pregnancy.
... Another significant population that deserves close attention during the COVID-19 pandemic is pregnant women [1]. Pregnancy condition is particularly susceptible to infectious diseases, and it is not surprising that viral infections can affect pregnancy outcomes [2][3][4]. ...
Aim. The present study aimed to investigate outcomes of pregnant women with severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2 or COVID-19) in the intensive care unit (ICU). Methods. A total of 3080 pregnant women infected with COVID-19 during treatment were studied in the maternity ward of the Zangiota-1 Republican Specialized Infectious Diseases Hospital from December 2020 to January, 2022. At the time of admission of patients to the hospital, 28.9% of women were in the first trimester of pregnancy, 34.3% and 36.8% were in the second and third trimester of pregnancy, respectively. 1980 cases (64.3%) showed a moderate course of pneumonia and in 48% (1478 cases), bilateral pneumonia was detected. At the same time, 60.0% of patients had lung damage (up to 50%) according to CT dataset. Results. A total of 677 out of 3080 pregnant women with COVID-19 pneumonia (22.0%) needed treatment at the ICU. 490 cases out of 677 patients showed severe clinical course of COVID-19, while 277 cases (41%) showed multiple organ dysfunction syndrome (MODS). Of 277 MODS cases, 209 (75.4%) were those in the third trimester of pregnancy and 170 (61.4%) had initially severe clinical picture of COVID-19. Mortality rate in ICU was 9.4% (64 cases out of 677) while 56.6% experienced post-traumatic stress disorder (PTSD) at baseline, 26.7% had general anxiety disorders, and 16.7% (113 of 677) of women experienced depression symptoms. In the postpartum period, 46.1% (312 of 677) cases showed combinations of PTSD, anxiety and depression according to the combined Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) assessment, which was typical for women with severe and extremely severe COVID-19, preterm birth, miscarriages and perinatal mortality. Conclusion. The ICU hospitalization rate for COVID-19 pneumonia in pregnant women was 22.0%, among which the vast majority (72.4%) were cases with severe clinical course of COVID-19 and PTSD (56.6%). Women in the third trimester of pregnancy were most susceptible to developing MODS and severe COVID-19 pneumonia. Recommendation. In promoting pregnant women's mental and physical health, understanding the characteristics of psycho-emotional stress disorders during the COVID-19 pandemic and learning how to deal with them is critical.
... Finally, during pregnancy there is an increase of thrombin production and an intravascular inflammation that results in a hypercoagulable state [6]. Thus, all these physiologic adaptations might trigger a severe course of pneumonia, with subsequent higher maternal and fetal morbidity and mortality [7,8]. ...
Full-text available
Background: It has been suggested that women experiencing during pregnancy several physiological and immunological changes that might increase the risk of any infection including the SARS-CoV-2. Objective: We aimed to quantify the risk of SARS-CoV-2 infection during pregnancy compared with women with no pregnancies. Methods: We used data from the BIFAP database and a published algorithm to identify all pregnancies during 2020. Pregnancies were matched (1:4) by age region, and length of pregnancy with a cohort of women of childbearing age. All women with SARS-CoV-2 infection before entering the study were discarded. We estimated incidence rates of SARS-CoV-2 with 95% confidence intervals (CIs) expressed by 1000 person-months as well as Kaplan-Meier figures overall and also stratified according to pregnancy period: during pregnancy, at puerperium (from end of pregnancy up to 42 days) and after pregnancy. (from 43 days after pregnancy up to end pf study period (i.e., June 2021). We conducted a Cox regression to assess risk factors for SARS-COV infection. The incidence rate of SARS-CoV-2 infection expressed by 1000 person-months were. Results: There was a total of 103,185 pregnancies and 412,740 matched women at childbearing, with a mean age of 32.3 years. The corresponding incidence rates of SARS-CoV-2 infection according to cohorts were: 2.44 cases per 1000 person-months (confidence interval (CI) 95%: 2.40-2.50) and 4.29 (95% CI: 4.15-4.43) for comparison cohort. The incidence rate ratio (IRR) of SARS-CoV-2 was 1.76 (95% CI: 1.69-1.83). When analyzing according to pregnancy period, the IRRs were 1.30 (95% CI: 11.20-1.41) during the puerperium and 1.19 (95% CI: 41.15-1.23) after pregnancy. In addition to pregnancy itself, other important risk factors were obesity (1.33 (95% CI: 1.23-1.44)) and diabetes (1.23 (95% CI: 11.00-1.50). Conclusion: Pregnant women are at increased risk of SARS-CoV-2 infection compared with women of childbearing age not pregnant. Nevertheless, there is a trend towards reverting during puerperium and after pregnancy.
Giriş: Gebelerin COVID-19 enfeksiyonundan korunmalarındaki ana kural izolasyon ve hijyen kurallarına dikkat etmeleridir. Bu noktada gebelerin bu kuralları biliyor ve uyguluyor olmaları anne-bebek sağlığı ve toplumsal olarak pandeminin önlenmesi açısından son derece önemlidir. Amaç: Çalışma pandemi sürecinde gebelerin, COVİD 19 bilgi düzeyleri ile koronavirüs anksiyetesi arasındaki ilişkiyi belirlemek amacıyla yapılmıştır. Yöntem: Kesitsel, tanımlayıcı ve ilişki arayan çalışma, 27 Mayıs-15 Haziran 2021 tarihleri arasında elektronik ortamda, 356 gebe ile yürütülmüştür. Verilerin toplanmasında; Tanıtıcı Bilgi Formu (TBF) ve Koronavirüs Anksiyete Ölçeği (KAÖ) kullanılmıştır. Verilerin değerlendirilmesinde; tanımlayıcı istatistikler için sayı, yüzde, ortalama, standart sapma, minimum, maksimum değerler kullanılmıştır. Veriler arasındaki ilişkiyi incelemek için Pearson Korelasyon analizi yapılmıştır. Yapılan istatistiksel testlerde p 0.05). Sonuçlar ve Öneriler: Çalışmada gebelerin COVİD-19 enfeksiyonu hakkındaki bilgi düzeylerinin yüksek, koronavirüs anksiyetesine düzeylerinin ise düşük olduğu belirlenmiştir. Gebelerin pandemi durumunda anksiyetelerinin kontrol edilebilmesi için etkili ve takipli bilgi kaynaklarının sunulması önerilir.
Background: Coronavirus disease 2019 (COVID-19) is difficult to treat in pregnant women due to pregnancy itself and the lack of standard treatment for the disease. As of August 2021, the etiotropic drug remdesivir has been added to the prescription list for women during gestation. There are few publications in the global scientific community regarding the use of this antiviral drug in pregnant women. Moreover, there are only sporadic scientific studies in Kazakhstan, so the question remains open. Objectives: This study aimed to evaluate the efficacy of remdesivir in pregnant women with probable or confirmed COVID-19. Methods: The study comprehensively examined 120 pregnant women with severe to very severe COVID-19, who were divided into two groups of patients. The study group consisted of women who received remdesivir and standard therapy. The control group included patients who received standard therapy per the protocol. Results: Statistically significant age differences were observed between the main and control groups (P = 0.019). The differences detected were due to a higher frequency in the age group of 33 and 42 years in patients taking remdesivir than in the control group (P = 0.036). Women in the main group (Median = 9.00; Q1 - Q3 = 8.00 - 11.0) had longer hospital stays than the control group (Me = 8.00; Q1 - Q3 = 7.00 - 10.0). This was due to the more severe condition of the patients in this group. There were statistically significant differences in amniotic fluid changes according to ultrasound between the control and main groups (P = 0.013). When comparing the groups in pairs, amniotic fluid was more common in women who received remdesivir (P = 0.316) than in the control group. Our study found that a decrease in temperature to normal levels occurred earlier in the control group (68%) than in the main group. Further SpO2 increases of more than 95% were seen on days 3 - 4 in the main group (71%) and days 1 - 2 in the control group (43%). After three days, there was an improvement in respiratory rate (41.6%) and a reduction in subjective dyspnea (66.6%) in the main group. Conclusions: The study found that repeat mothers have a more severe course of COVID-19. The older age group and the third trimester of pregnancy are risk factors for progression to severe disease.
Full-text available
Background: Stillbirth has been recognized as a possible complication of a SARS-CoV-2 infection during pregnancy, probably due to destructive placental lesions (SARS-CoV-2 placentitis). The aim of this work is to analyse stillbirth and late miscarriage cases in unvaccinated pregnant women infected with SARS-CoV-2 during the first two waves (wild-type period) in Belgium. Methods: Stillbirths and late miscarriages in our prospective observational nationwide registry of SARS-CoV-2 infected pregnant women (n = 982) were classified by three authors using a modified WHO-UMC classification system for standardized case causality assessment. Results: Our cohort included 982 hospitalised pregnant women infected with SARS-CoV-2, with 23 fetal demises (10 late miscarriages from 12 to 22 weeks of gestational age and 13 stillbirths). The stillbirth rate was 9.5‰ for singleton pregnancies and 83.3‰ for multiple pregnancies, which seems higher than for the background population (respectively 5.6‰ and 13.8‰). The agreement between assessors about the causal relationship with SARS-Cov-2 infection was fair (global weighted kappa value of 0.66). Among these demises, 17.4% (4/23) were "certainly" attributable to SARS-CoV-2 infection, 13.0% (3/23) "probably" and 30.4% (7/23) "possibly". Better agreement in the rating was noticed when pathological examination of the placenta and identification of the virus were available, underlining the importance of a thorough investigation in case of intra-uterine fetal demise. Conclusions: SARS-CoV-2 causality assessment of late miscarriage and stillbirth cases in our Belgian nationwide case series has shown that half of the fetal losses could be attributable to SARS-CoV-2. We must consider in future epidemic emergencies to rigorously investigate cases of intra-uterine fetal demise and to store placental tissue and other material for future analyses.
Background: This study aims to determine the effect of parents' levels of COVID-19 phobia on the risk of abuse and neglect towards their children. Subjects and methods: A total of 472 parents, who have children between the ages of 0-18, who use social media and volunteer to participate in the research, were included in the study. The sociodemographic information form, Corona Virus 19 Phobia Scale (C19P-S), and Abuse Awareness Scale-Parent Form were used to collect the study's data. Results: 57.9% of the parents participating in the study were female, and the mean age was 42.08±10.33. It was found that 55.9% of the participants continued to go to the workplace during the COVID-19 pandemic. While 12% of the parents were treated for COVID-19, 21.4% were quarantined. The average C19P-S score of the parents was found to be 50.2. The mean score of the sub-dimensions of the scale varies between 8.4 and 18.5. The average score of the parents from the Abuse Awareness Scale-Parent Form was 55.4. A positive correlation was found between the Abuse Awareness Scale-Parent Form and the C19P-S score averages. Conclusion: The findings have shown that the family's risk of children being exposed to abuse and neglect increases due to the negativities experienced during the pandemic period.
Full-text available
ntroduction: With the outbreak of the novel coronavirus disease (Covid-19), some of the population groups are more vulnerable than others. Among these groups, one can name pregnant women who should be given particular attention in the studies and presentation of health and treatment protocols. This study aimed to overview the findings related to Covid-19 and health recommendations during pregnancy. Materials and Methods: This review included studies investigating different types of coronaviruses indexed in databases, such as SID, Magiran, PubMed, Scholar, science direct, Embase, and Scopus, as well as clinical protocols and reports of reputable health organizations during 2000 to 2020. The search terms were "Pregnancy", "Coronavirus", "novel Coronavirus", "Covid 19", "Acute Respiratory Syndrome", "Breastfeeding" and "Infants". Finally, 23 studies met the requirements and reviewed in this study. Results: This study investigated the findings related to the effects of coronavirus during pregnancy on pregnant women and their fetuses, disease diagnosis methods, care protocols in pregnant women, and postpartum care. The data in this review are based on the studies, updated protocols, and valid statistics. Conclusion: Due to the global prevalence of this virus, protocols and health care applied to other people should be also applied to pregnant women. Moreover, preventive measures should be taught and implemented at the community level concerning pregnant women, and monitoring systems should be considered for infected and non-infected pregnant women so that they can be specifically monitored and followed up during pregnancy.
В марте 2020 г. ВОЗ объявила пандемию коронавирусной инфекции (SARS-CoV-2). К середине марта 2021 г. во всем мире этой инфекцией заболели 119 млн человек, выздоровели 94,7 млн человек, у 2,6 млн наступил летальный исход. [1] В настоящее время имеются немногочисленные данные о влиянии коронавирусной инфекции COVID-19 на течение беременности, родов, состояние плода и послеродовый период. Имеются противоречивые данные относительно большей подверженности беременных женщин коронавирусной инфекции из-за изменений в организме (прежде всего, в органах дыхательной и иммунной системы). Ранее считалось, что беременные не подвержены заражению инфекцией сильнее, чем население в целом. [2] Ряд публикаций из Китая, Италии и США свидетельствовали о том, что беременные женщины имеют равноценное с общей популяцией взрослых людей течение COVID-19 [3,4,5]. В настоящее время показано, что заболеваемость у беременных COVID-19 выше, чем в популяции [6,7]. Установлено, что из-за своих уникальных иммунных характеристик и восприимчивости к респираторным патогенам беременные, инфицированные SARS-CoV-2, должны рассматриваться как группа высокого риска тяжелой заболеваемости и смертности, поскольку имеют ряд перинатальных осложнений, по сравнению с популяцией в целом.
Full-text available
Objectives: Person-to-person spread of COVID-19 in the UK has now been confirmed. There are limited case series reporting the impact on women affected by coronavirus during pregnancy. In women affected by severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), the case fatality rate appeared higher in those affected in pregnancy compared with non-pregnant women. We conducted a rapid review to guide health policy and management of women affected by COVID-19 during pregnancy, which was used to develop the Royal College of Obstetricians and Gynaecologists' (RCOG) guidelines on COVID-19 infection in pregnancy. Methods: Searches were conducted in PubMed and MedRxiv to identify primary case reports, case series, observational studies and randomized controlled trials describing women affected by coronavirus in pregnancy. Data were extracted from relevant papers. This review has been used to develop guidelines with representatives of the Royal College of Paediatrics and Child Health (RCPCH) and RCOG who provided expert consensus on areas in which data were lacking. Results: From 9965 search results in PubMed and 600 in MedRxiv, 23 relevant studies, all of which were case reports or case series, were identified. From reports of 32 women to date affected by COVID-19 in pregnancy, delivering 30 babies (one set of twins, three ongoing pregnancies), seven (22%) were asymptomatic and two (6%) were admitted to the intensive care unit (ICU), one of whom remained on extracorporeal membrane oxygenation. No maternal deaths have been reported to date. Delivery was by Cesarean section in 27 cases and by vaginal delivery in two, and 15 (47%) delivered preterm. There was one stillbirth and one neonatal death. In 25 babies, no cases of vertical transmission were reported; 15 were reported as being tested with reverse transcription polymerase chain reaction after delivery. Case fatality rates for SARS and MERS were 15% and 27%, respectively. SARS was associated with miscarriage or intrauterine death in five cases, and fetal growth restriction was noted in two ongoing pregnancies affected by SARS in the third trimester. Conclusions: Serious morbidity occurred in 2/32 women with COVID-19, both of whom required ICU care. Compared with SARS and MERS, COVID-19 appears less lethal, acknowledging the limited number of cases reported to date and that one woman remains in a critical condition. Preterm delivery affected 47% of women hospitalized with COVID-19, which may put considerable pressure on neonatal services if the UK's reasonable worst-case scenario of 80% of the population being affected is realized. Based on this review, RCOG, in consultation with RCPCH, developed guidance for delivery and neonatal care in pregnancies affected by COVID-19, which recommends that delivery mode be determined primarily by obstetric indication and recommends against routine separation of affected mothers and their babies. We hope that this review will be helpful for maternity and neonatal services planning their response to COVID-19.
Full-text available
BACKGROUND Person to person spread of COIVD-19 in the UK has now been confirmed. There are limited case series reporting the impact on women affected by coronaviruses (CoV) during pregnancy. In women affected by SARS and MERS, the case fatality rate appeared higher in women affected in pregnancy compared with non-pregnant women. We conducted a rapid, review to guide management of women affected by COVID -19 during pregnancy and developed interim practice guidance with the RCOG and RCPCH to inform maternity and neonatal service planning METHODS Searches were conducted in PubMed and MedRxiv to identify primary case reports, case series, observational studies or randomised-controlled trial describing women affected by coronavirus in pregnancy and on neonates. Data was extracted from relevant papers and the review was drafted with representatives of the RCPCH and RCOG who also provided expert consensus on areas where data were lacking RESULTS From 9964 results on PubMed and 600 on MedRxiv, 18 relevant studies (case reports and case series) were identified. There was inconsistent reporting of maternal, perinatal and neonatal outcomes across case reports and series concerning COVID-19, SARS, MERS and other coronaviruses. From reports of 19 women to date affected by COVID-19 in pregnancy, delivering 20 babies, 3 (16%) were asymptomatic, 1 (5%) was admitted to ICU and no maternal deaths have been reported. Deliveries were 17 by caesarean section, 2 by vaginal delivery, 8 (42%) delivered pre-term. There was one neonatal death, in 15 babies who were tested there was no evidence of vertical transmission. CONCLUSIONS Morbidity and mortality from COVID-19 appears less marked than for SARS and MERS, acknowledging the limited number of cases reported to date. Pre-term delivery affected 42% of women hospitalised with COVID-19, which may put considerable pressure on neonatal services if the UK reasonable worse-case scenario of 80% of the population affected is realised. There has been no evidence of vertical transmission to date. The RCOG and RCPCH have provided interim guidance to help maternity and neonatal services plan their response to COVID-19.
Full-text available
The World Health Organization (WHO) has declared the outbreak of novel coronavirus (2019‐nCoV) – now known as Coronavirus Disease (COVID‐19)1 ‐ as a global health emergency. Singapore currently stands as the country with the highest number of reported cases of COVID‐19 outside of China2, excluding patients on a cruise ship offshore of Japan.
OBJECTIVE. The objective of our study was to determine the misdiagnosis rate of radiologists for coronavirus disease 2019 (COVID-19) and evaluate the performance of chest CT in the diagnosis and management of COVID-19. The CT features of COVID-19 are reported and compared with the CT features of other viruses to familiarize radiologists with possible CT patterns. MATERIALS AND METHODS. This study included the first 51 patients with a diagnosis of COVID-19 infection confirmed by nucleic acid testing (23 women and 28 men; age range, 26-83 years) and two patients with adenovirus (one woman and one man; ages, 58 and 66 years). We reviewed the clinical information, CT images, and corresponding image reports of these 53 patients. The CT images included images from 99 chest CT examinations, including initial and follow-up CT studies. We compared the image reports of the initial CT study with the laboratory test results and identified CT patterns suggestive of viral infection. RESULTS. COVID-19 was misdiagnosed as a common infection at the initial CT study in two inpatients with underlying disease and COVID-19. Viral pneumonia was correctly diagnosed at the initial CT study in the remaining 49 patients with COVID-19 and two patients with adenovirus. These patients were isolated and obtained treatment. Ground-glass opacities (GGOs) and consolidation with or without vascular enlargement, interlobular septal thickening, and air bronchogram sign are common CT features of COVID-19. The The "reversed halo" sign and pulmonary nodules with a halo sign are uncommon CT features. The CT findings of COVID-19 overlap with the CT findings of adenovirus infection. There are differences as well as similarities in the CT features of COVID-19 compared with those of the severe acute respiratory syndrome. CONCLUSION. We found that chest CT had a low rate of missed diagnosis of COVID-19 (3.9%, 2/51) and may be useful as a standard method for the rapid diagnosis of COVID-19 to optimize the management of patients. However, CT is still limited for identifying specific viruses and distinguishing between viruses.
OBJECTIVE. The increasing number of cases of confirmed coronavirus disease (COVID-19) in China is striking. The purpose of this study was to investigate the relation between chest CT findings and the clinical conditions of COVID-19 pneumonia. MATERIALS AND METHODS. Data on 101 cases of COVID-19 pneumonia were retrospectively collected from four institutions in Hunan, China. Basic clinical characteristics and detailed imaging features were evaluated and compared between two groups on the basis of clinical status: nonemergency (mild or common disease) and emergency (severe or fatal disease). RESULTS. Patients 21-50 years old accounted for most (70.2%) of the cohort, and five (5.0%) patients had disease associated with a family outbreak. Most patients (78.2%) had fever as the onset symptom. Most patients with COVID-19 pneumonia had typical imaging features, such as ground-glass opacities (GGO) (87 [86.1%]) or mixed GGO and consolidation (65 [64.4%]), vascular enlargement in the lesion (72 [71.3%]), and traction bronchiectasis (53 [52.5%]). Lesions present on CT images were more likely to have a peripheral distribution (88 [87.1%]) and bilateral involvement (83 [82.2%]) and be lower lung predominant (55 [54.5%]) and multifocal (55 [54.5%]). Patients in the emergency group were older than those in the non-emergency group. Architectural distortion, traction bronchiectasis, and CT involvement score aided in evaluation of the severity and extent of the disease. CONCLUSION. Patients with confirmed COVID-19 pneumonia have typical imaging features that can be helpful in early screening of highly suspected cases and in evaluation of the severity and extent of disease. Most patients with COVID-19 pneumonia have GGO or mixed GGO and consolidation and vascular enlargement in the lesion. Lesions are more likely to have peripheral distribution and bilateral involvement and be lower lung predominant and multifocal. CT involvement score can help in evaluation of the severity and extent of the disease.