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Ultrasound Obstet Gynecol 2020
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.22013
isuog.org 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:
WHO: https://www.who.int/emergencies/diseases/nov
el-coronavirus-2019
Centers for Disease Control and Prevention (CDC):
https://www.cdc.gov/coronavirus/2019-ncov/specific-gro
ups/pregnancy-faq.html
Pan American Health Organization (PAHO):
http://www.paho.org
European Centre for Disease Prevention and Control
(ECDC): https://www.ecdc.europa.eu
Public Health England: https://www.gov.uk/guidance/
coronavirus-covid-19-information-for-the-public
National Health Commission of the People’s Republic
of China: http://www.nhc.gov.cn
Perinatal Medicine Branch of Chinese Medical Associa-
tion: https://mp.weixin.qq.com/s/11hbxlPh317es1XtfWG
2qg
Indicazioni ad interim della Societa Italiana di Neona-
tologia (SIN): https://www.policlinico.mi.it/uploads/fom/
attachments/pagine/pagine_m/79/files/allegati/539/
allattamento_e_infezione_da_sars-cov-2_indicazioni_ad_
interim_della_societ___italiana_di_neonatologia_sin__
2_.pdf
Sant´
e Publique France https://www.santepubliquefran
ce.fr/
Sociedad Espa ˜
nola de Ginecolog´
ıa y Obstetricia
S.E.G.O.: https://mcusercontent.com/fbf1db3cf76a76d
43c634a0e7/files/1abd1fa8-1a6f-409d-b622-c50e2b29
eca9/RECOMENDACIONES_PARA_LA_PREVENCIO
_N_DE_LA_INFECCIO_N_Y_EL_CONTROL_DE_LA_
ENFERMEDAD_POR_CORONAVIRUS_2019_COVID
_19_EN_LA_PACIENTE_OBSTE_TRICA.pdf
Royal College of Obstetricians and Gynaecolo-
gists (RCOG): https://www.rcog.org.uk/globalassets/
documents/guidelines/coronavirus-covid-19-infection-in-
pregnancy-v3-20-03-18.pdf
BACKGROUND
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
beyond1–3.
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-CoV5–9. 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 2–2.5. The latest report from
WHO12,onMarch3
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
management.
DIAGNOSIS OF INFECTION AND
CLINICAL CLASSIFICATION
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
coronavirus’18.
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;
OR
•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
following:
•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 1–2 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 RADIOGRAPHY DURING
PREGNANCY
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 0.0005–0.01 mGy,
which is negligible, while the radiation dose to the fetus is
0.01–0.66 mGy from a single chest CT or CT pulmonary
angiogram28–30.
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.
TREATMENT DURING PREGNANCY
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 1–2 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
available.
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
necessary.
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, maternal–fetal-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
≥26–28 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.
MANAGEMENT DURING PREGNANCY
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 2–4-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.
ULTRASOUND EQUIPMENT
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.
MANAGEMENT DURING CHILDBIRTH
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
anesthetist.
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, maternal–fetal-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
undertaken.
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 mother–baby 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 mother–baby 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
needed55.
PERINATAL EFFECT OF COVID-19
INFECTION
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 16–29 weeks of
gestation, in the 8321 pregnant women with a reported
temperature >38◦C 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 18–24 weeks of gestation is indicated for pregnant
women with suspected, probable or confirmed COVID-19
infection.
GENERAL PRECAUTIONS
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
department.
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
alternative.
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.
KEY POINTS FOR CONSIDERATION
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
ICU.
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, maternal–fetal-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
anesthetist.
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
pregnancy.
12. There is currently insufficient evidence regarding the
safety of breastfeeding and the need for mother–baby
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.
AUTHORS
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
CI TAT I O N
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.
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APPENDICES
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
criteria.
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.
