COVID 19 IN PREGNANT FEMALES RECENT ADVANCES.pptx

THIS PRESENTATION IS ABOUT COVID 19 IN PREGNANT FEMALES

1. COVID 19 IN PREGNANGY BY – DR. MONIKA CHANDRA MODERATOR – DR(PROF) N.R.AGRAWAL

2. INTRODUCTION Agent : novel corona virus called as COVID – 19. earlier called as SARS- COV Incubation period: range 2.2 to 11.5 days. Median 5.1 days Mode of transmission : mainly droplet infection, also by contact and fomites Symptoms : cough, URTI, fever, shortness of breath(SOB), myalgia, headache, loss of smell and taste, gastrointestinal symptoms like nausea, vomiting and diarrhoea , sore throat

3. How does COVID -19 affect pregnancy Normally respiratory infections in pregnant females have increased morbidity and mortality due to decrease lung capacity and due to decrease immune response. Earlier reports showed pregnant females do not appear to be more susceptible to consequences of infection of covid 19 than general population Recent reports shows pregnant female with covid 19 appear to be at increase risk of certain manifestations as compared to non pregnant females : ICU admission, mechanical ventilation , anxiety and depression. But there is no increase in rate of mortality

4. Pregnant female with comorbidities like obesity, hypertension, diabetes , heart disease are likely to be at increased risk consistent with non pregnant females with similar comorbidities. Even if Pregnant female is infected,>=90% recovered without undergoing delivery. More than two thirds of pregnant women with covid 19 are asymptomatic.

5. Compared to pregnant women without COVID19, pregnant women with symptomatic COVID 19 requiring hospitalization have overall worse maternal outcomes , including an increase risk of death , although that risk remains very low.

6. INFECTION TO FETUS 1 . Congenital infection( vertical transmission) If virus is confirmed in amniotic fluid prior to rupture of membrane Virus is confirmed in umbilical cord blood by RT PCR Virus is confirmed in neonatal blood by RT PCR All to be done within first 12 hours of birth. Vertical transmission is infrequent.

7. 2. Intrapartum infection: If nasopharyngeal swab taken at birth and at 24-48hours after birth both are positive 3. Postpartum infection If nasopharyngeal swab is negative at birth but positive after 24-48 hours after birth This is most common mode of spread.

8. Effect on fetus Theoretically hyperthermia in covid 19 may be associated with increase risk of congenital anomalies especially neural tube defects or miscarriage. No data suggests increase risk of abortion or increase risk of teratogenicity, therefore COVID 19 is not an indication for MTP. There is increased risk of 1. Preterm labour and premature rupture of membrane 2. Abnormal fetal heart rate patterns 3. Increase in rate of caesarean deliveries 4. Suboptimal fetal growth due to placental insufficiency

9. Risk in fetus in women who have recovered from covid? ANC care remains unchanged. Critically ill patients to get USG 15 days post discharge. FGR is associated with SARS.

10. SYMPTOMS Symptoms of covid in pregnancy are same as non pregnant female or general population Classification of disease severity : 1 . Asymptomatic or pre-symptomatic infection: Positive test for SARS-COV-2 but no symptoms 2 . Mild illness: any signs and symptoms ( eg . Fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnoea or abnormal chest imaging.

11. 3 . Moderate illness: evidence of lower respiratory disease by clinical assessment or imaging and SpO2>93% on room air at sea level 4 . Severe illness: respiratory rate>30 breaths per minute,SpO2<93% on room air, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen( PaO2/FiO2) < 300, or lung infiltrates >50% 5 . Critical illness : respiratory failure, septic shock and/or multiple organ dysfunction

12. Complications of COVID 19 Respiratory disorders: pneumonia, respiratory failure, ARDS Cardiac disorders : arrhythmias, acute cardia injury Thromboembolic complications Secondary infection Acute kidney injury

13. Neurological disorders: headache, dizziness, myalgia, alteration of consciousness, disorder of smell and taste, weakness, stroke, seizures Cutaneous disorders: morbilliform rash, urticaria, acral lesion, livedo like vascular lesion Gastrointestinal and liver disorders Psychiatric illness : anxiety, depression, insomnia, post traumatic stress disorder

14. Investigations controversies Chest radiograph is sufficient for initial evaluation of pulmonary complications . A single chest radiograph carries a very low fetal radiation of 0.0005 to 0.01mGy.( maximum permissible exposure of radiation to fetus is 5Gy) Computed tomography(CT) should be performed if indicated as fetal radiation dose for a routine CT is (0.01 to 0.66rad) low and not associated with increase risk of fetal anomalies or pregnancy loss . Abdominal shielding can be used to protect the fetus as per normal protocols.

15. Inflammatory markers are raised in normal pregnancy Management is based on clinical judgement rather than blood reports.

16. ANTENATAL VISITS Reduced to 4 antenatal visits According to ICMR guidelines: 12weeks: genetic screening(aneuploidy screening) 20 weeks: morphological scan( level 2 scan) 28weeks: routine investigation including testing for gestational diabetes and tetanus toxoid injection 36weeks: group b streptococci culture, check lie and presentation FIGO includes antenatal visit at 32 weeks also

17. MANAGEMENT Pregnant female with SARS-COV2 exposure Get RTPCR done ASYMPTOMATIC SYMPTOMATIC Fever >38 C AND respiratory symptoms MONITOR at home for temperature, respiratory symptoms Monitor at hospital

18. Monitor at home for temperature, respiratory symptoms Monitor at hospital NEGATIVE Stop monitoring POSITIVE Isolate at home for 14 days Do USG fetal surveillance for growth and doppler every 2 weeks. Monitor daily movement counts. NEGATIVE Isolate at home for 14 days If symptoms persists then repeat RTPCR test after 24-48 hours. POSITIVE Monitor at hospital M ATERNAL Temp, HR,RR,BP.(3-4 times daily) CXR ,CT FETAL FHR monitoring Inj dexona for lung maturity< 34weeks

19. Icu admission ICU admission needed if Quick Sequential Organ Failure Score(QSOFA) IF more than one following criteria Systolic BP<100mmHg Respiratory rate>22 Altered mental status( GCS<15)

20. DRUGS IN PREGNANCY DRUG PREGNANCY LACTATION Vitamin c(500-1000mg/day) Yes Yes Zinc 50mg/day Yes Yes Budesonide inhalation Yes Yes Steroids Benefit vs Risk Benefit vs Risk Favipiravir No No Remdesivir Benefit vs Risk Benefit vs Risk

21. Drugs with proven no benefit in pregnancy Hydroxychloroquine, Lopinavir, ritonavir, and azithromycin are shown to be ineffective in treatment of COVID 19 infection. DRUGS WHICH ARE USED IN SEVERE DISEASE : Plasma monoclonal antibodies, Tocilizumab , Itolizumab , Baricitinib

22. Prevention of Venous thromoembolism Women in isolation should be mobile and well hydrated Those with high risk of VTE - should be given LMWH Women already on LMWH to continue the treatment All pregnant women admitted for treatment to start LMWH unless delivery expected in 12hours All pregnant women with sever disease should continue LMWH 10days post discharge Postpartum covid infection requiring admission (within 6 weeks)- to start LMWH and continue 10 days post discharge Women on aspirin can continue the same.

23. heparin There is increase risk of thromboembolic events in covid19 patients and since pregnancy is a hypercoagulable state hence heparin should be started in all pregnant female who are covid positive. Heparin : for pregnant females near to delivery unfractionated heparin 5000 units subcutaneously every 12hourly For pregnant females unlikely to deliver within several days and those who are postpartum: inj enoxaparin 40mg daily till patient is covid positive.

24. steroids Dexamethasone: Pregnant female who is severely ill with risk of preterm labour : inj dexona 6mg 12hourly 4injections or inj betamethasone 12mg 24hourly 2 injections. Followed by prednisolone 10mg oral daily or inj hydrocortisone 80mg iv twice daily. This prevents fetus from unnecessary prolonged steroid exposure as dexamethasone can cross placenta.

25. Antiviral ( remdesivir ) Adenosine analog Early tried in Ebola virus Dose: single iv 200mg loading dose followed by 100mg daily infusion for 5days Can be given in pregnancy and lactation if benefit outweighs the risk Fetal risk profile of remdesivir is unknown Adverse effects: kidney injury.

26. Lopinavir / Ritonavir Used in HIV, now in china it was used against covid19 Lopinavir : no category in pregnancy Ritonavir: category b drug Therefore it is a possible therapeutic option in pregnant female.

27. Chloroquine/hydroxychloroquine It inhibits virus entry and has immunomodulator properties. This drug is banned by WHO but recommended by ICMR Adverse effects: QT prolongation( therefore should be avoided with drugs which prolong QT interval like azithromycin) Hypoglycemia, Retinopathy Neuropsychiatric symptoms Hemolysis in G6PD deficiency HCQ crosses placenta. Therefore should be used carefully in pregnancy. Till date no adverse effects has been reported

28. Role of magnesium sulphate Magnesium sulphate can be given for neuroprotection Non-intubated patients with respiratory compromise----monitor carefully(magnesium levels , respiratory rates , pulse oximetry) since high magnesium levels(10-13mEq/L) can cause respiratory paralysis. COVID19 related acute renal injury--- dose adjusting magnesium sulfate rather than withholding the drug In intubated, mechanically ventilated patients, sign of magnesium related respiratory toxicity will not be observed. Thus cardiac arrhythmias or arrest can be the first sign of serious toxicity.

29. Delivery Time of delivery: should not be changed based on covid positive status In severe/ critically ill patients, delivery can be considered >=32-34weeks If before 24 weeks POG in severe maternal illness: consider MTP (if legal) Mode of delivery: should not be influenced by covid positive status unless her respiratory condition demands urgent delivery. Best mode of delivery: vaginal delivery If during labour patient becomes hypoxic then 2 nd stage of labour should be cut down using forceps or vaccum .

30. There is no contraindication to epidural analgesia. Indications for cesarean section: F etal distress A cute organ failure S eptic shock O bstetric indications. SEVERE FAILURE CRITERIA

31. ACOG recommends delayed cord clamping. At present there is no evidence that delayed cord clamping or skin to skin contact increases the risk of transmission of infection to the baby.

32. Management in labour Full maternal and fetal assessment Maternal temperature, respiratory rate and oxygen saturation Confirm onset of labour, Electronic fetal monitoring No evidence to favour one mode of delivery above another Infection control team(physician, chest physician, hematologist ), obstetrician, anaesthetist, neonotologist , intensive care team Oxygen saturation maintained above 94% Regular monitoring, minimal staff members entering room

33. Third stage of labour PPH can be managed by standard protocols. Oxytocin and PGE1 care safe to use Some avoid tranexamic acid due to its antifibrinolytic properties and risk of thrombosis Some avoid methylergometrine and PGF 2alfa due to vasoconstrictive properties.

34. Postnatal care Asymptomatic /mild symptoms with healthy baby – mother and child can remain together. Normal feeding and rooming in protocols To wear mask during feeding Wash handing with soap and water Avoid coughing or sneezing on the baby Women with mild symptoms and baby needing neonatal care(premature, RDS, etc ) precautionary measures and counselling. Keep barrier or 6 feet distance from baby Covid19 is not a contraindication for breastfeeding If temporary separation warranted, breast pump can be used to express milk

35. Criteria for discontinuing mother newborn infection precautions Symptomatic mothers : potential risk of virus transmission to their neonates is eliminated if all of the following criteria is met At least 10days have passed since symptoms first appeared( upto 20days if they have more severe to critical illness or are severely immunocompromised) At least 24hours have passed since their last fever without the use of antipyretics. Symptoms have improved Asymptomatic mothers : for asymptomatic mothers at least 10 days should have passed since the positive test

36. Vaccination Pregnant women should receive vaccine only if the benefit outweighs the potential vaccine risk. Information and counselling on lack of safety data for pregnant women should be provided. WHO does not recommend pregnancy testing prior to vaccination. WHO does not recommend delaying pregnancy because of vaccination. A interval of minimum 14 days is must for covid vaccine if some other vaccine is taken prior.

37. Counselling for vaccination in pregnant women The benefits of vaccination includes: Reduction in severe disease for the pregnant women Reduction in the risk of prematurity for the baby Potentially reducing transmission to vulnerable household members

38. Vaccination to pregnant women Vaccination should be offered to the following groups of pregnant women: Those with high risk medical conditions who have a greater risk of severe illness from covid19 Health or social care workers who are at very high risk of catching covid19 Women diagnosed with gestational diabetes in pregnancy or pregnant women with a BMI of more than 40 Individuals aged 45 or over

39. Lactation Covid 19 vaccines pose no risk for lactating mother or their infants. Therefore lactating woman may choose to be vaccinated. To be given if benefit outweighs risk. WHO does not recommend discontinuing breastfeeding after vaccination.

40. Inadvertent pregnancy following vaccination Women who find out they are pregnant during their vaccine series or shortly afterward should not be counselled to terminate pregnancy based on having received the vaccine. If the first dose has been received but the second dose is pending, the decision of whether to complete the vaccine series during pregnancy should be based on an assessment of the potential risks of not being completely vaccinated during pregnancy versus taking the vaccine during pregnancy.

41. Side effects of vaccination Common side effects include local and systemic reactions, including pain at injection site, ipsilateral axillary lymph node enlargement, fever, fatigue and headache. Rare Prothrombotic Thrombocytopenic Disorder resembling Heparin Induced thrombocytopenia has been noted.

42. THANK YOU…