SARS-CoV-2 in Pregnancy: A Comprehensive Summary of Current Guidelines

Abstract

Since the declaration of the global pandemic of COVID-19 by the World Health Organization on 11 March 2020, we have continued to see a steady rise in the number of patients infected by SARS-CoV-2. However, there is still very limited data on the course and outcomes of this serious infection in a vulnerable population of pregnant patients and their fetuses. International perinatal societies and institutions including SMFM, ACOG, RCOG, ISUOG, CDC, CNGOF, ISS/SIEOG, and CatSalut have released guidelines for the care of these patients. We aim to summarize these current guidelines in a comprehensive review for patients, healthcare workers, and healthcare institutions. We included 15 papers from 10 societies through a literature search of direct review of society's websites and their journal publications up till 20 April 2020. Recommendations specific to antepartum, intrapartum, and postpartum were abstracted from the publications and summarized into Tables. The summary of guidelines for the management of COVID-19 in pregnancy across different perinatal societies is fairly consistent, with some variation in the strength of recommendations. It is important to recognize that these guidelines are frequently updated, as we continue to learn more about the course and impact of COVID-19 in pregnancy.

Full text

Journal of
Clinical Medicine
Review
SARS-CoV-2 in Pregnancy: A Comprehensive
Summary of Current Guidelines
Kavita Narang 1, Eniola R. Ibirogba 1, Amro Elrefaei 1, Ayssa Teles Abrao Trad 1,
Regan Theiler 2, Roseli Nomura 3, Olivier Picone 4, Mark Kilby 5, Ramón Escuriet 6,
Anna Suy 7, Elena Carreras 7, Gabriele Tonni 8and Rodrigo Ruano 1 ,*
1Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of
Medicine, 200 First Street SW, Rochester, MN 55905, USA; Narang.Kavita@mayo.edu (K.N.);
Ibirogba.Eniola@mayo.edu (E.R.I.); Elrefaei.Amro@mayo.edu (A.E.);
TelesAbraoTrad.Ayssa@mayo.edu (A.T.A.T.)
2Obstetrics Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, 200 First
Street SW, Rochester, MN 55905, USA; Theiler.Regan@mayo.edu
3
Department of Obstetrics and Gynecology, Escola Paulista de Medicina—Universidade Federal de S
ã
o Paulo,
São Paulo 04021, Brazil; roseli.nomura@hotmail.com
4Groupe de Recherche sur les Infections pendant la Grossesse (GRIG), CNGOF, Service de
Gynécologie-Obstétrique Colombes, Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Universitéde
Paris, Inserm IAME-U1137, 75000 Paris, France; olivier.picone@aphp.fr
5
Fetal Medicine Centre, Birmingham Women’s and Children’s Foundation Trust, College of Medical & Dental
Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK; M.D.KILBY@bham.ac.uk
6Catalan Health Service, Government of Catalonia, 080028 Barcelona, Spain; rescuriet@gencat.cat
7Department of Obstetrics and Gynecology, Hospital Universitari Vall d’Hebron, 080028 Barcelona, Spain;
asuy@vhebron.net (A.S.); ecarreras@vhebron.net (E.C.)
8
Prenatal Diagnostic Division, Department of Obstetrics and Gynecology, AUSL di Reggio Emilia Istituto di
Ricerca a Carattere Clinico Scientifico, 42100 Reggio Emilia, Italy; Gabriele.Tonni@ausl.re.it
*Correspondence: ruano.rodrigo@mayo.edu; Tel.: +1-507-284-0210; Fax: +1-507-284-9684
Received: 5 May 2020; Accepted: 14 May 2020; Published: 18 May 2020


Abstract:
Since the declaration of the global pandemic of COVID-19 by the World Health Organization
on 11 March 2020, we have continued to see a steady rise in the number of patients infected by
SARS-CoV-2. However, there is still very limited data on the course and outcomes of this serious
infection in a vulnerable population of pregnant patients and their fetuses. International perinatal
societies and institutions including SMFM, ACOG, RCOG, ISUOG, CDC, CNGOF, ISS/SIEOG,
and CatSalut have released guidelines for the care of these patients. We aim to summarize these
current guidelines in a comprehensive review for patients, healthcare workers, and healthcare
institutions. We included 15 papers from 10 societies through a literature search of direct review of
society’s websites and their journal publications up till 20 April 2020. Recommendations specific to
antepartum, intrapartum, and postpartum were abstracted from the publications and summarized into
Tables. The summary of guidelines for the management of COVID-19 in pregnancy across different
perinatal societies is fairly consistent, with some variation in the strength of recommendations. It is
important to recognize that these guidelines are frequently updated, as we continue to learn more
about the course and impact of COVID-19 in pregnancy.
Keywords:
coronavirus; COVID-19; pandemic; SARS-CoV-2; pregnancy; guidelines; prevention;
screening; perinatal
J. Clin. Med. 2020,9, 1521; doi:10.3390/jcm9051521 www.mdpi.com/journal/jcm

J. Clin. Med. 2020,9, 1521 2 of 22
1. Introduction
The World Health Organization (WHO) declared a global pandemic of COVID-19, caused by
SARS-CoV-2 on 11 March 2020 [
1
]. The rapidly escalating numbers of individuals infected globally
remain on the rise and little is still known about the course and outcomes of this serious infection in a
vulnerable population of pregnant patients and their fetuses.
A variety of professional societies and institutions involved in the care of pregnant patients
including Society for Maternal and Fetal Medicine (SMFM) [
2
,
3
] from United States, American College
of Obstetrics and Gynecology (ACOG) [
4
,
5
] from United States, Royal College of Obstetrics and
Gynecology (RCOG) [
6
] from United Kingdom, International Society for Ultrasound in Obstetrics
and Gynecology (ISUOG) [
7
], United States Centers of disease control (CDC) [
8
,
9
]. In World Health
Organization (WHO) [
10
], College National de Gynecologie et Obstetrique Francais (CNGOF) [
11
]
from France, Istituto Superiore di Sanit
à
/Societ
à
Italiana di Ecografia Ostetrico Ginecologica
(
ISS/SIEOG) [12,13]
from Italy, and the Catalan Health Service (CatSalut) [
14
] from Spain have released
independent guidelines for the assessment and care of pregnant patients from prenatal course to
intrapartum to postpartum.
A paper published by Boelig et al. in March 2020 [
3
] to guide Maternal Fetal Medicine specialists
on the care of SARS-Cov-2 pregnant patients urged healthcare providers and their institution to develop
internal guidelines to have their unit ready to care for these patients.
In order to help institutions keep up with this rapidly evolving landscape. In authors of this paper
aim to summarize and discuss all the current guidelines put forth by the aforementioned professional
societies and institutions into one document. The goal is to allow institutions access to a comprehensive
summary of guidelines related to the SARS-Cov-2 pandemic in pregnancies, which they can adapt to
their practice environment and capabilities. The primary focus of all published guidelines is to design
a model where patients and their families, as well as healthcare workers (HCW) in the frontline of the
pandemic are protected and prepared.
2. Experimental Section
Perinatal guidelines that are frequently cited in the United States include publications by SMFM,
ACOG, and ISUOG. However, to encompass a global picture and include guidelines that can be
generalized to a larger patient population, we included some international guidelines from five
countries (US, UK, Italy, Spain, and France). These were selected based on our collaboration with the
co-authors from the respective countries to help with translation of documents or clinical application
relevance; these societies include RCOG from United Kingdom, CNGOF from France, CatSalut from
Spain, and ISS/SIEOG from Italy. Publications from outside of United States were selected by authors
affiliated with that country, respectively. We also included WHO and CDC for their expertise in global
health care and infectious diseases, respectively.
A literature search was performed through direct review of all the aforementioned society’s
website and journal publications and PubMed. Guidelines published between December 2019 and
20 April 2020
, with selection of the most updated versions, were included. The search plan for SMFM,
ACOG, and RCOG were arranged and done by two authors K.N. and E.I. with input from the study’s
principal investigator—R.R. RCOG publication was reviewed by author M.K. from the UK, CNFOG
was reviewed, selected and translated by author O.P., CatSalut publication was reviewed, selected,
and translated by authors R.E., A.S., E.C. from Spain, and ISS/SEIOG was reviewed, selected and
translated by author G.T. from Italy—all applying the Preferred Reporting Items for Systematic Reviews
and Meta Analyses (PRISMA) guidelines for the data extraction and quality assessment. Keywords
used to search include COVID-19 and/or SARS-CoV-2 infection in pregnancy and the name of the
society. Publications were included if they are an original document from the society, if they outline
details on management of patients either during antepartum, intrapartum or postpartum, and if
they were expert opinions or expert guidance. Exclusion criteria include case series, case reports,
retrospective cohort studies, systematic reviews, or metanalyses. ACOG, SMFM, ISS, and CDC had

J. Clin. Med. 2020,9, 1521 3 of 22
two publications relevant to guidance for perinatal care and were all included. All other societies
had one publication each. A total of 15 papers were identified from 10 societies and reviewed by two
authors (K.N. and E.I.) who were in agreement. The list of publications included are summarized in
(Table 1), arranged in ascending order of publication date.
Table 1. Sources of evidence.
Journal/Website Professional
Society/Institution Publication Title Publication
Date
ISS website
https://www.iss.it/coronavirus [
12
]
Superior Institute of
Health
Educational course on
Health Emergency on
novel Coronavirus
28 February 2020
UOG Journal
https://obgyn.onlinelibrary.wiley.
com/doi/10.1002/uog.22013 [7]
ISUOG (International
Society)
ISUOG Interim
Guidance on 2019 novel
coronavirus infection
during pregnancy and
puerperium: information
for healthcare
professionals
12 March 2020
ACOG website
https://www.acog.org/clinical/
clinical-guidance/practice-
advisory/articles/2020/03/novel-
coronavirus-2019 [4]
ACOG (United States) Novel Coronavirus 2019-
Practice advisory 13 March 2020
CDC website
https://www.cdc.gov/coronavirus/
2019-ncov/hcp/index.html [9]
CDC (United States)
Information for
Healthcare Providers:
COVID-19 and Pregnant
women
16 March 2020
WHO website
https://www.who.int/
reproductivehealth/publications/
maternal_perinatal_health/anc-
positive-pregnancy-experience/
en/[10]
WHO (International
Society)
Q&A on COVID-19,
pregnancy, childbirth,
and breastfeeding
18 March 2020
AJOG-MFM Journal
https:
//www.sciencedirect.com/science/
article/pii/S2589933320300367 [3]
SMFM (United States) MFM Guidance for
COVID-19 19 March 2020
CNGOF
https://pubmed.ncbi.nlm.nih.gov/
32199996/[11]
CNGOF (France)
SARS-CoV-2 infection
during pregnancy.
Information and
proposal of management
care. CNGOF
19 March 2020
CatSalut Website
https://canalsalut.gencat.cat/ca/
salut-a-z/c/coronavirus-2019-
ncov/professionals/consulta/?cat=
8460bdf4-691a-11ea-88fa-
005056924a59&submit=true [14]
CatSalut (Barcelona)
SARS-CoV-2 coronavirus
infection
Information for pregnant
women and their
families.
20 March 2020
ACOG website
https://www.acog.org/clinical-
information/physician-faqs/
covid-19-faqs-for-ob-gyns-
obstetrics [5]
ACOG (United States)
COVID-19 FAQs for
Obstetrician-Gynecologists,
Obstetrics
23 March 2020

J. Clin. Med. 2020,9, 1521 4 of 22
Table 1. Cont.
Journal/Website Professional
Society/Institution Publication Title Publication
Date
AJOG-MFM Journal
https:
//www.sciencedirect.com/science/
article/pii/S2589933320300409 [2]
SMFM (United States) Labor and Delivery
Guidance for COVID-19 25 March 2020
ISS website
https://www.iss.it/coronavirus [
12
]
Superior Institute of
Health (Italy)
Rational use of
individual protection
devices in the assistance
of Covid-19 patients
28 March 2020
SIEOG website
https://www.sieog.it/events/
emergenza-covid19/[13]
Italian Society for
Ultrasound in Obstetrics
and Gynecology (Italy)
SARS-Cov-2 Pandemic:
Information and
Recommendation
29 March 2020
CDC website
https:
//www.cdc.gov/coronavirus/2019-
ncov/need-extra-precautions/
pregnancy-breastfeeding.html [8]
CDC (United States) COVID-19: Pregnancy
and breastfeeding 3 April 2020
CatSalut Website
https://canalsalut.gencat.cat/ca/
salut-a-z/c/coronavirus-2019-
ncov/professionals/consulta/?cat=
8460bdf4-691a-11ea-88fa-
005056924a59&submit=true [14]
CatSalut (Barcelona)
Clinical guideline for
new cases of
SARS-CoV-2 coronavirus
infection in pregnant
women and infants
6 April 2020
RCOG Journal
https:
//www.rcog.org.uk/globalassets/
documents/guidelines/2020-04-
17-coronavirus-covid-19-
infection-in-pregnancy.pdf [6]
RCOG (United
Kingdom)
COVID-19 infection in
pregnancy 17 April 2020
All the publications were thoroughly reviewed and important points of discussions were abstracted
and summarized into antepartum, intrapartum, and postpartum management, as discussed in the
next section. Not all publications addressed every aspect of care, but we summarized the most
salient points in each publication in order to highlight the similarities and differences amongst these
international guidelines.
3. Results
After reviewing all the publications, information was classified into antepartum, intrapartum, or
postpartum management and was summarized in a systematic fashion into Tables 2–4, respectively.
•
Prenatal and antepartum care (See Table 2): Reviewed guidelines support some form of screening
of pregnant patients depending on symptoms and exposure, use of telehealth is encouraged for
prenatal visits, while limiting face to face visits and ultrasounds only to those that are medically
necessary. Prenatal appointments, lab work, and ultrasounds should be scheduled on the same
day if possible. All ultrasound equipment and patient rooms should be appropriately cleaned
after each use. The use of antenatal corticosteroids for fetal lung maturation can be continued till
34 weeks gestation, but the use of steroids in the late preterm period, >34 0/7 weeks gestation
remains controversial.
•
Intrapartum care (See Table 3): Reviewed guidelines recommend a designated area within the
unit to care for SARS-CoV-2 positive pregnant patients or Person under investigation (PUI).
Timing and mode of delivery should follow routine obstetric indications. Cesarean section

J. Clin. Med. 2020,9, 1521 5 of 22
(CS) should be reserved for obstetric indications only; infection with SARS-CoV-2 is not an
indication for cesarean delivery unless there is acute decompensation of mother or fetus. Only one
consistent asymptomatic support person is allowed to be present at time of delivery. Patients and
healthcare workers should be appropriately gowned, gloved, and have protective face masks;
specifically, N95 should be used for aerosol generating procedures such as forceful expiration
during pushing, use of oxygen for intrauterine resuscitation, or intubation. Use of operative
delivery to shorten the second stage of labor can be considered for routine obstetric indications.
There is no contraindication to regional or general anesthesia if indicated, but appropriate personal
protective equipment (PPE) use is encouraged.
•
Postpartum care (See Table 4): Reviewed guidelines encourage early discharge from the hospital,
one day for vaginal delivery and two days for cesarean delivery. This limits face to face exposure
and increases bed availability. Separation of mother and baby or discouraging breastfeeding are
not advised, unless the mother is acutely ill. However, mothers are encouraged to (1) practice
respiratory hygiene during feeding, (2) wear a mask, (3) wash hands before and after touching the
baby, and (4) routinely clean and disinfect surfaces they have touched. If breastpumping is used,
all equipment should be cleaned thoroughly before and after each use. Postpartum visits should
be performed over telehealth, unless face to face visit is essential to management.

J. Clin. Med. 2020,9, 1521 6 of 22
Table 2. Summary of guidelines for antepartum care of pregnant patients during the COVID-19 pandemic.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
PRENATAL
CARE AND
ANTEPARTUM
Infection
Screening
Set up triage
screening
area. All
outpatients
should be
assessed and
screened for
TOCC and
symptoms.
All HCW
should wear
appropriate
PPE. All
suspected
cases should
be screened
with
qRT-PCR.
Repeat
testing in 24
hr if
negative, but
still high
suspicion.
Chest CT
should be
considered,
if high
suspicion
Set up triage
screening area
Patients should be
provided with a
surgical mask at the
entrance (and is not to
be removed until the
patient is isolated in a
suitable room). All
outpatients should be
assessed and screened
for TOCC and
symptoms. All HCW
should wear
appropriate PPE. All
suspected cases
should be screened
with qRT-PCR.
Symptomatic patients
should be treated as
positive till results are
back
Patients with
suspected COVID-19
who present with
obstetric emergency
should be transferred
immediately to an
isolation room by
HCW using
appropriate PPE.
Obstetric
management should
not be delayed for
COVID-19 testing
Routine
screening
before
appointment,
if suspicious.
If
symptomatic,
initiate
testing and
notify health
department,
mark patient
as PUI.
Screening
algorithm
https:
//www.acog.
org/-/media/
project/acog/
acogorg/
files/pdfs/
clinical-
guidance/
practice-
advisory/
covid-19-
algorithm.
pdf. All
HCW
should wear
PPE (Face
mask, Eye
protection,
gloves,
and gown)
Triage
symptomatic
patients via
telehealth.
Test anyone
with new
flu-like
symptoms,
especially
older,
immune-
compromised,
advanced
HIV,
homeless,
hemodialysis.
Utilize drive
through or
standalone
testing area.
Symptomatic
patients
should be
treated as
positive till
results are
back
Patients should be
provided with a
surgical mask at the
entrance (and is not to
be removed until the
patient is isolated in a
suitable room). Screen
all patients presenting
to maternity unit.
Patients who meet
criteria (see guideline
for details) for potential
COVID-19should have
a full blood count
evaluation; if
lymphopenia is
identified, COVID-19
testing should be
arranged. Patients with
suspected COVID-19
who present with
obstetric emergency
should be transferred
immediately to an
isolation room by HCW
using appropriate PPE.
Obstetric management
should not be delayed
for COVID-19 testing
Symptomatic patients
should be treated as
positive till results are
back
-Testing
protocols
and
eligibility
vary
depending
on where
you live.
Symptomatic
and high
risk patients
should get
screening
priority.
HCW
should
maintain
hand
hygiene,
and appropriate
use of
protective
clothing like
gloves,
gown,
and medical
mask.
Same as
general
population
Women are
asked to
phone prior
to antenatal
visit. All
women
should take
preventive
measures
when
attending
health care
settings.
Screen
women with
symptoms
presenting
to antenatal
clinic.
Symptomatic
patients
should be
treated as
positive till
negative
results are
back
Telephone
triage.
Screen with
symptoms
Asymptomatic
mothers:
respect
hygiene
measures,
social
distancing.
PPE not
required.
Symptomatic
mothers:
individual
PPE
required for
mothers and
HCW.
Symptomatic
mothers are
tested for
SARS-CoV-2
using
nasopharyngeal
swabs and
isolation in a
dedicated
room. Public
Hygiene
Service
should be
informed.

J. Clin. Med. 2020,9, 1521 7 of 22
Table 2. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
Place of
care
Negative
pressure or
single
isolation
rooms in
tertiary care
center.
Reserve ICU
for critical
patients
Isolation room for
patients with
suspected/confirmed
COVID-19 for whom
care cannot be safely
delayed for
self-isolation
N/A
Designated
COVID-19
area within
the facility
Isolation room for
patients with
suspected/confirmed
COVID-19 for whom
care cannot be safely
delayed for
self-isolation
−N/A
Same as
general
population
Same as
general
population.
If hospital
admission is
needed,
women are
referred to
one
reference
hospital in
the Region
Asymptomatic:
delivery at
General
Hospitals.
Stable
symptomatic
mothers
delivery at
General
hospital
with
designated
area within
the facility.
Delivery in
isolated
room.
Mothers,
medical staff
and a single
accompanying
person must
wear PPE.
Room
ventilation
at least with
60 L/s.
Mothers &
babies are
kept in
isolated
room.
Unstable
symptomatic
mothers
delivery at
tertiary care
center with
ICU facilities

J. Clin. Med. 2020,9, 1521 8 of 22
Table 2. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
Prenatal
appointment
Postpone by
14 days if
positive or
until 2
negative
results
Elective and
non-urgent
appointments should
be postponed or
completed by
telehealth. Encourage
use of telehealth for
all visits–HCW
meetings should all
be virtual/audio.
Keep some providers
at home. No support
persona at outpatient
visit
If, after
screening.
In patient
reports
symptoms of
or exposure
to a person
with
COVID-19,
that patient
should be
instructed
not to come
to the health
care facility
for their
appointment
and health
care
clinicians
should
contact the
local or state
health
department
to report the
patient as a
possible
person
under
investigation
(PUI)
Elective and
non-urgent
appointments
should be
postponed
or
completed
by telehealth.
Encourage
use of
telehealth
for all visits.
HCW
meetings
should all be
virtual/audio.
Keep some
providers at
home. No
support
persona at
outpatient
visit. Labs
and US at
the same
appointment.
Provide
patient with
ambulatory
BP
cuff/machine.
F2F visits at
11-13,20,28,36
weeks and
weekly after
37 weeks
-Routine appointments
for women with
suspected/confirmed
COVID 19 should be
delayed until after the
recommender period of
self-isolation. For
symptomatic patients,
defer appointments
until 7 days after
symptom onset; defer
appointments for 14
days for patients with
symptomatic household
contacts. Encourage the
use of telephone for
non-urgent
consultation/enquiries
N/A N/A
Encourage
use of
telehealth
for all visits
Routine
antenatal
care
appointment
monthly for
asymptomatic
mothers.
Planned
visit @ at
maternity
unit at 37-38
weeks and
then at 40
weeks, if
physiologic
pregnancy.
Symptomatic
mothers:
delay
appointments
for several
days
according to
symptoms,
recommend
GP
consultation
and keep
telephone
contacts

J. Clin. Med. 2020,9, 1521 9 of 22
Table 2. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
Ultrasound
frequency
Suspected,
asymptomatic
confirmed
and
recovering
patients: US
q 2–4 weeks
for Fetal
growth and
AFI, UA
dopplers if
indicated
Continue US as
medically indicated
when possible.
Continue US
as medically
indicated
when
possible.
Elective US
should not
be
performed.
Postpone or
cancel
testing or
examinations
if the risk of
exposure
and
infection
within the
community
outweighs
the benefit of
testing.
Combine
dating and
NT in 1st
trimester.
Anatomy
scan at 20–22
weeks.
Consider
stopping
serial CL
after
anatomy
US if TVUS
CL ≥35 mm,
prior
preterm
birth at >34
Weeks. BMI
>40:
schedule at
22 weeks to
reduce risk
of
suboptimal
views/need
for follow
up. Single
growth F/U
at 32 weeks.
Low lying
placenta F/U
34–36 wks.
Refer to
primary
publication
for disease
specific US
frequency
In addition to routine
ultrasound surveillance,
fetal growth restriction
surveillance is
recommended 14 days
after resolution of acute
illness due to
theoretical risk of
growth restriction.
N/A N/A
Continue US
as medically
indicated
when
possible
Asymptomatic
mothers:
continue US
assessment
as routine.
Symptomatic
mothers:
following 14
days of
isolations
and
resolution of
symptoms,
general
clinical
examination
and
ultrasound
assessment
for fetal
growth
every 3–4
weeks

J. Clin. Med. 2020,9, 1521 10 of 22
Table 2. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
Ultrasound
Equipment/
patient
rooms
Must be
cleaned with
disinfectant
per
manufacturer
guidelines
after EVERY
use
Deep clean
of all
instruments
and room in
case of
positive
patient
Must be cleaned with
disinfectant per
manufacturer
guidelines after
EVERY use
N/A
Wipe down
patient
rooms after
every visit of
suspected
SARS-COV-2
patients
-Decontaminate after
use on suspected or
confirmed SARS-CoV-2
patients
N/A N/A
Deep clean
of all
instruments
and room in
case of
positive
patient
Deep clean
of all
instruments
and room
ventilation
every 10 min
Antenatal
corticoster
oids
(BMZ)
Avoid in
critically ill
patient; risk
of
worsening
disease
Should continue if
<34 weeks, even if
tested positive for
SARS-CoV-2
Should
continue if
<34 weeks,
even if
tested
positive for
COVID-19
Controversial
for 34 0/7–36
6/7 Weeks
Other
modifications
should be
individualized
Judicious
use <34
weeks
Avoid >34
weeks
Administer for routine
indications
No evidence to suggest
harm in the context of
SARS-CoV-2 infection
N/A N/A
Administer
for routine
indications
N/A

J. Clin. Med. 2020,9, 1521 11 of 22
Table 2. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
GBS
screening
Delay by
14days in
patients
with TOCC
risk factors
As indicated between,
36 0/7–37 6/7 weeks
gestation.
As indicated
between, 36
0/7–37 6/7
weeks
gestation.
Patients can
self-collect
with proper
instructions
if the
resources
and
infrastructure
allow
Routine
screening at
36wks
N/A−N/A N/ARoutine
screening
Routine
screening
Antenatal
surveillance
(BPP,
NST)
N/ADaily NST if patient
hospitalized
Reserve for
medically
indicated
screening
During
acute illness,
fetal
management
should be
similar to
that
provided to
any ill
pregnant
person.
Limit NSTs
if <32 wks
Twice
weekly NST
only for FGR
with
abnormal
UA Doppler
studies
If patient
needs US,
perform BPP
instead of
NST
Kick counts
instead of
NST for low
risk patients
N/A N/A N/A N/A N/A
Travel history, occupation, significant contact and cluster (TOCC), Healthcare worker (HCW), Personal protective equipment (PPE), Face to face (F2F), General practitioner (GP), Nuchal
Translucency (NT), Follow up (F/U), Ultrasound (UA), fetal growth restriction (FGR), Non-stress test (NST), Biophysical profile (BPP).

J. Clin. Med. 2020,9, 1521 12 of 22
Table 3. Summary of guidelines for intrapartum care of pregnant patients during the COVID-19 pandemic.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
INTRAPARTUM
CARE
Pre-Delivery
preparation
Social
distancing
Social
distancing
Obstetric,
pediatric or
family
medicine,
and anesthesia
teams
should be
notified in
order to
facilitate
care.
Social
distancing
and offwork
for 2 weeks
prior to
anticipated
delivery
(start at
~37wks).
Screen
patient and
partner on
phone day
before
admission.
Institution
should run
simulations
Minimum
staffing and
social distancing.
Screen patient
and partner at
maternity unit.
Partners with
symptoms less
than 7 days
prior should be
instructed to
self-isolate and
not be allowed
into the
maternity unit.
Women with
suspected or
confirmed
COVID19
should be
encouraged to
remain at home
during early
labor; women in
active labor
should be
admitted to an
isolation room.
Dry run
simulations for
elective/emergency
procedures
If COVID19
is suspected
or
confirmed,
health
workers
should take
all
appropriate
precautions
to reduce
risks of
infection to
themselves
and others,
including
hand
hygiene,
and appropriate
use of
protective
clothing like
gloves,
gown and
medical
mask.
N/A
Screen
women with
symptoms at
maternity
unit
Respectful
care must be
always
considered
minimum
number of
professionals
attending
women.
Only one
partner
allowed for
companionship
during labor
and delivery.
Screen
women with
symptoms at
maternity
unit.
Asymptomatic:
as per
routine care.
Stable
Symptomatic
patients
admit to
hospital.
Unstable
symptomatic
patients:
refer to
hospitals
with ICU
facility

J. Clin. Med. 2020,9, 1521 13 of 22
Table 3. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
Delivery
Time
Based on
routine
obstetric
indications
Early
delivery
should be
considered
for
critically ill
patients
If infection
in early
pregnancy
with
recovery,
No
alterations
in delivery
time.
Based on
routine
obstetric
indications
Early
delivery
should be
considered
for
critically ill
patients
If infection
in early
pregnancy
with
recovery, No
alterations
in delivery
time.
If infection
in late
pregnancy
and recovery,
postpone
delivery (if
no other
medical
indications
arise) until a
negative
testing result
is obtained
or
quarantine
status is
lifted in an
attempt to
avoid
transmission
to the
neonate.
COVID-19 is
not an
indication of
delivery.
Based on
routine
indications.
No
contraindication
to induction
of labor
unless beds
are limited.
For term
COVID-19
patients,
consider
delivery
because
symptoms
peak in 1–2
weeks after
onset
Based on routine
indications N/A N/A
PPE in all
cases.
Continuous
fetal
electronic
monitoring.
Per routine
Obstetric
indications

J. Clin. Med. 2020,9, 1521 14 of 22
Table 3. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
Delivery
location
Designated
negative
pressure
isolation
room
Designated
isolation
room, for
suspected
or
confirmed
cases of
COVID-19
N/A
Designated
delivery and
operating
rooms
Designated
isolation room,
for suspected or
confirmed cases
N/A N/A
Designed
isolation
room for
suspected or
confirmed
cases of
COVID-19.
Designed
negative
pressure
isolation
room for CS
Designated
isolated
room for
suspected or
confirmed
cases
Mode of
Delivery
Based on
routine
obstetric
indications
Infection is
NOT an
indication
for CS.
Expedite
delivery
by CS in
setting of
fetal
distress or
maternal
deterioration.
Water birth
should be
avoided
Based on
routine
obstetric
indications
Infection is
NOT an
indication
for CS.
Expedite
delivery
by CS in
setting of
fetal
distress or
maternal
deterioration
Per routine
obstetric
indications.
No specific
recommendations
for CS.
Operative
vaginal
delivery is
not
indicated for
suspected or
confirmed
cases alone,
but can be
used as
routinely
indicated
Based on
routine
obstetric
indications.
Infection is
NOT an
indication
for CS
Based on
routine obstetric
indications
unless maternal
respiratory
condition
demands early
delivery. Water
birth should be
avoided.
As clinically
indicated N/A
Based on
routine
obstetric
indications.
Infection is
not an
indication
for CS
Routine
obstetric
indications.
Infection is
not an
indication
for CS

J. Clin. Med. 2020,9, 1521 15 of 22
Table 3. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
Support
person
Limit
visitors, no
clear
number
specified
No visitor
Allowed one
consistent
asymptomatic
support
person
Allowed one
consistent
support
person. No
children
<16–18 y/o
Allowed one
consistent
asymptomatic
support person
who should be
restricted to the
patient’s
bedside.
N/A N/A
Companionship
by one
person
relative to
the women
is
encouraged
during all
the labor
and delivery
Single
accompanying
asymptomatic
person
Obstetric
Analgesia
and
Anesthesia
Regional
anesthesia
and GA
can be
considered
Regional
anesthesia
and GA
can be
considered
N/A
Avoid use of
nitrous
oxide
NO evidence
against regional
or GA. Epidural
analgesia is
recommended
in suspected or
confirmed cases,
to minimize the
need for GA if
urgent delivery
is needed.
N/A N/A
Epidural
analgesia is
recommended
to women
with
suspected or
confirmed
COVID-19
to minimize
the need for
GA if urgent
delivery is
needed.
Regional
and GA can
be
considered
Second
Stage of
Labor
Consider
shortening
with
operative
delivery to
minimize
aerosolization
and
maternal
respiratory
effort
N/A N/A
Do not delay
pushing.
Considered
aerosolizing,
N95 should
be worn by
HCW and
patients
Consider
shortening with
operative
vaginal delivery
in symptomatic
women who
become
exhausted or
hypoxic
N/A N/A N/A N/A

J. Clin. Med. 2020,9, 1521 16 of 22
Table 3. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
Third stage
of Labor N/A N/A
Active
management
to reduce
blood loss
(national
blood
shortage)
N/A N/A N/A
Active
management
in all cases
Per routine
Oxygen
supplementa
tion
N/A N/A N/A
Considered
aerosolizing,
HCW must
wear
appropriate
PPE. Do not
use O2for
intrauterine
resuscitation
Hourly O2sat
measurements
(in addition to
routine
maternal-fetal
observations)
for women with
suspected/
confirmed
COVID-19. Aim
to keep o2sat
>94%, titrating
O2therapy
accordingly.
N/A N/A N/A N/A
Umbilical
cord
clamping
Avoid
delayed
cord
clamping
in
confirmed
and
suspected
cases
N/A
No
recommendations
against
delayed
clamping of
Umbilical
cord.
Avoid
delayed cord
clamping
Delayed cord
clamping is still
recommended
in the absence of
contraindications
N/A N/A
Delayed
cord
clamping is
still
recommended
in the
absence of
contraindications
General rule

J. Clin. Med. 2020,9, 1521 17 of 22
Table 3. Cont.
TITLE Professional
Society ISUOG CNGOF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
PPE use N/A N/A
Asymptomatic
or negative
patients
Patient and
provider
wear
surgical
mask.
Aerosolizing
procedures-
N95 for
patient and
N95, gown,
gloves, face
shield for
provider
Level of PPE
should be based
on the risk of
requiring GA.
Aerosolizing
procedures-use
FFP3 mask
N/A
Same as
general
population
N/A
Symptomatic
with stable
or unstable
condition:
Mothers,
medical staff
and
accompanying
person must
wear all
protection
devices.
Masks
should be
FFP2/FFP3
type.
Elective
Cesarean
delivery/
induction of
labor (IOL)
N/A N/A
No
contraindica
tion to IOL
unless there
is limited
beds
For
suspected/confirmed
cases, consider
delay of elective
CD or IOL if
safely feasible to
N/A N/A N/A N/A
General anesthesia (GA), Quantitative real time polymerase chain reaction (qRT-PCR), Ultrasound (US), Umbilical artery (UA), Biophysical profile (BPP), Non stress test (NST), Cesarean
Section (CS).

J. Clin. Med. 2020,9, 1521 18 of 22
Table 4. Summary of guidelines for postpartum care of pregnant patients during the COVID-19 pandemic.
TITLE Professional
Society ISUOG CNOGF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
POSTPARTUM
CARE
Placental or
fetal tissue
Should be
handled as
infectious
tissue in
positive
patients
Consider
qRT-PCR on
placenta
N/A N/A N/A N/A N/A N/A N/A N/A
Length of
stay N/A N/A
Expedited
discharge
should be
considered.
VD—1 day
CS—2 days
Expedited
discharge should
be considered.
VD—1 day
CS—2 days
N/A N/A
Same as
general
population
Expedited
discharge
should be
considered
Asymptomatic
→2 days
Symptomatic
→3 days
Breastfeeding
Insufficient
evidence
Okay for
asymptomatic
patients,
mothers
should use
masks and
wash hands
Separation
and breast
pumping
suggested in
critically ill
patients
Limited
evidence to
advise against
breastfeeding.
Advise patients
to: wash hands
before handling
baby, touching
pumps or bottle;
avoid coughing
while baby is
feeding;
consider
wearing face
mask while
feeding or
handling baby;
N/A
Advice patients to:
wash hands
before handling
baby, touching
pumps or bottle;
avoid coughing
while baby is
feeding; consider
wearing face mask
while feeding or
handling baby; if
breast pump us
used, clean
properly after
each use; consider
asking someone
who is well to
feed baby.
No contradictions
Advice patients to:
wash hands before
handling baby,
touching pumps or
bottle; avoid
coughing while
baby is feeding;
consider wearing
face mask while
feeding or handling
baby; if breast
pump us used, clean
properly after each
use; consider asking
someone who is
well to feed baby.
Women with
COVID-19 can
breastfeed if they
wish to do so.
They should:
(1) Practice
respiratory
hygiene during
feeding
(2) wear a mask
(3) Wash hands
before and after
touching the baby
(4) Routinely clean
and disinfect
surfaces they have
touched.
During
separation
encourage
dedicated
breast pump.
Mother
should use a
facemask
and practice
hand
hygiene after
each feeding
Encourage
breastfeeding
support
(1) Practice
respiratory
hygiene
during
breastfeeding.
(2) wear a
mask
(3) hands
and tissues
hygiene
before and
after
breastfeeding
Encourage
breastfeeding
support.
Symptomatic:
(1) hands
and tissue
hygiene
(2) wear a
surgical
mask

J. Clin. Med. 2020,9, 1521 19 of 22
Table 4. Cont.
TITLE Professional
Society ISUOG CNOGF ACOG SMFM RCOG WHO CDC CatSalut ISS/SIEOG
Skin to skin
Can be
considered
with
appropriate
PPE use for
asymptomatic
patients
N/A N/A N/A
Routine
precautionary
separation of a
healthy baby and
mother is not
advised at this
point.
Allow with
precautions and
good hygiene
clean.
N/A
Individualize
according to
the
conditions of
the mother
and the baby
N/A
Postpartum
pain control N/A N/A N/A
No
contraindication
to NSAID use
N/A N/A N/A N/A N/A
Postpartum
visit N/A
Encourage
telehealth for
postpartum visit
Encourage
telehealth
for
postpartum
visit. Delay
comprehensive
face to face
postpartum
visit to 12
weeks. Use
telehealth
before 12
weeks.
Encourage
telehealth for
postpartum visit
Encourage
telehealth for
postpartum visit
N/A N/A
Stay at home
policy and
encourage of
telehealth
postpartum
visits
home visit
by health
professional
(midwife)
between
48–72 h after
discharge
N/A
Vaginal Delivery (VD), Cesarean Section (CS).

J. Clin. Med. 2020,9, 1521 20 of 22
4. Discussion
The summary of the reviewed guidelines for the management of COVID-19 in pregnancy across
different professional societies and institutions is consistent, with some variation in the strength of
recommendations. Global societies such as WHO and CDC have a similar approach to their guideline
publication, keeping their recommendations broad so it can be utilized across all shapes and sizes of
healthcare institutions. Many of their recommendations overlap with those for the general population
and they provide great resources to guide readers to perinatal societies for more specific questions.
International perinatal societies, including ACOG, RCOG, SMFM, ISUOG, CNGOF, ISS/SIEOG,
and public institution CatSalut, all share similar recommendations answering questions that are
very specific to the care of pregnant patients—from prenatal screening, antepartum care, details
of intrapartum care during different stages of labor in emergency and non-emergency settings to
postpartum care and follow up. The guidelines put forth by SMFM (United States) are most specific to
the care of high risk pregnancies, given their expertise in this field. ACOG (United States) and RCOG
(United Kingdom) summarize recommendations that are suitable for lower risk pregnant patients.
CNGOF (France) and ISS/SIEOG (Italy) and CatSalut (Barcelona) give some practical recommendations
for the management of infected pregnant women. ISUOG (International) provides more information
specific to managing and cleaning ultrasound equipment—an essential tool in the care of pregnant
patients, which could be a vector for disease transmission if sanitization is not a priority.
The consensus amongst all perinatal societies encourages all institutions to transition to telehealth
when appropriate and limit the number of face to face visits. Ultrasounds and antenatal surveillance
should be performed only if medically indicated. The use of antenatal steroids for fetal lung maturation
for patients at high risk of preterm birth within seven days should still be performed if pregnancy is
between 24 0/7 to 33 6/7 weeks gestation, but use during late preterm of 34 0/7 to 36 6/7 weeks gestation
is still controversial. All institutions should set up a designated screening area, labor and delivery
rooms, and operating rooms for SARS-CoV-2 infected patients. All patients should be screened for
symptoms, travel history, contact history, and follow the appropriate algorithm provided to guide
need for performing real time PCR tests. If elective procedures or induction of labor is scheduled,
patients should first be screened and triaged over the phone, followed by a nasopharyngeal swab for
SARS-CoV-2 infection. This screening should be done within a time frame to allow the test results to
return before the scheduled procedure date. For urgent or emergent obstetric conditions, screening for
SARS-CoV-2 should be performed right away, but procedures should not be delayed for results to
return; patients should be treated as a PUI and managed as presumptive positive.
As the numbers of testing sites and resources have increased over the past few weeks, there should
be consideration for screening every pregnant patient being admitted, regardless of exposure, history
or symptoms. Societies recommend only one consistent support person to be present during delivery.
Mode and timing of delivery should still be performed on the basis of routine obstetric indications,
and delivery should be expedited with cesarean delivery in the event of maternal deterioration due
to severe COVID-19 disease or fetal distress. Aerosol generating procedures such as the use of
supplemental oxygen, intubation, and forceful pushing should be avoided to protect everyone in the
delivery room. Appropriate PPE should be donned by patients and healthcare workers during all
interactions. N95 should be worn during aerosol generating procedures.
Currently, there is no definitive evidence to suggest vertical transmission of SARS-CoV-2. As a
result, mother and baby separation and discouraging breastfeeding are not advised unless the mother
is acutely ill. Mothers who are acutely ill with SARS-CoV-2 infection are advised the option for breast
pumping, and to wash hands before handling baby or touching pumps or bottle, avoid coughing while
baby is feeding, and consider wearing a face mask while feeding or handling baby. If a breast pump is
used, clean properly after each use and routinely clean all surfaces that are touched. The length of
hospital stay should be decreased to one day for vaginal delivery and two days for cesarean delivery
to limit time of exposure for patients and healthcare workers in the hospital while also increasing bed
capacity. Once discharged, patients are advised to continue social distancing, and routine postpartum

J. Clin. Med. 2020,9, 1521 21 of 22
visits can be conducted using telehealth. The method of telehealth should be individualized based on
institution resources and availability.
5. Conclusions
The present manuscript summarizes the guidelines for Obstetrical and perinatal management of
pregnant women during the SARS-CoV-2 pandemic, which can be an overall reference for Obstetricians
all over the world. Many similarities are identified amongst these guidelines. All of the international
professional societies and institutions discussed in this paper, including ACOG, RCOG, SMFM, ISUOG,
WHO, CNGOF, ISS/SIEOG, CatSalut and CDC, continue to work tirelessly to put forth updated
information for the care of pregnant patients and beyond. This manuscript also provides the summary
of the source for continuous updates. It is imperative for readers to continue to use the most updated
guidelines available as we continue to learn more about the impacts of the SARS-Cov-2 pandemic
in pregnancy.
Author Contributions:
Conceptualization, K.N. and R.R.; methodology, E.R.I., A.E., and A.T.A.T.; validation,
K.N., and R.R.; formal analysis, K.N.; investigation, K.N., R.R., R.T.; data curation, K.N., E.R.I., A.E., A.T.A.T., O.P.,
M.K., R.E., A.S., E.C., G.T., R.R.; writing—original draft preparation, K.N.; writing—review and editing, K.N.,
E.R.I., A.E., A.T.A.T., O.P., M.K., R.E., A.S., E.C., G.T., R.N., R.R.; supervision, R.R. All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.
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©
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article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).