Produção Nacional
Revisado por pares
ISUOG Interim Guidance on coronavirus disease 2019 (COVID‐19) during pregnancy and puerperium: information for healthcare professionals – an update
2020; Wiley; Volume: 55; Issue: 6 Linguagem: Inglês
10.1002/uog.22061
ISSN1469-0705
AutoresLiona C. Poon, Huixia Yang, Sander Dumont, Jill Cheng Sim Lee, Joshua A. Copel, Lieven Danneels, A Wright, Fabrício da Silva Costa, Miriam T. Y. Leung, Y. Zhang, Denghong Chen, Federico Prefumo,
Tópico(s)Maternal and fetal healthcare
ResumoIn response to the World Health Organization (WHO) statements and international concerns regarding the coronavirus disease 2019 (COVID-19) outbreak, the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is issuing the following guidance for management during pregnancy and puerperium. Given the uncertainty regarding many aspects of the clinical course of COVID-19 in pregnancy, frequently updated information may help obstetricians and ultrasound practitioners in counseling pregnant women and further improve our understanding of the pathophysiology of COVID-19 in pregnancy. This statement, which is an update on our previous Interim Guidance1 (Appendix S1), is not intended to replace other previously published interim guidance on evaluation and management of COVID-19-exposed pregnant women and should be considered in conjunction with relevant advice from organizations such as: American College of Obstetricians and Gynecologists (ACOG): https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics Centers for Disease Control and Prevention (CDC): https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html European Centre for Disease Prevention and Control (ECDC): https://www.ecdc.europa.eu Indicazioni ad interim della Societa Italiana di Neonatologia (SIN): https://www.sin-neonatologia.it/wp-content/uploads/2020/03/SIN.COVID19-10-maggio.V3-Indicazioni-1.pdf International Federation of Gynecology and Obstetrics (FIGO): https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/ijgo.13156 Ministry of Health, Brazil: https://www.conasems.org.br/wp-content/uploads/2020/03/guia_de_vigilancia_2020.pdf National Health Commission of the People's Republic of China: http://www.nhc.gov.cn Pan American Health Organization (PAHO): http://www.paho.org Perinatal Medicine Branch of Chinese Medical Association: https://mp.weixin.qq.com/s/11hbxlPh317es1XtfWG2qg Public Health England: https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public Royal College of Obstetricians and Gynaecologists (RCOG): https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/ Santé Publique France: https://www.santepubliquefrance.fr/ Sociedad Española de Ginecología y Obstetricia (S.E.G.O.): https://mcusercontent.com/fbf1db3cf76a76d43c634a0e7/files/1abd1fa8-1a6f-409d-b622-c50e2b29eca9/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 Society for Maternal-Fetal Medicine: https://www.smfm.org/covidclinical World Health Organization (WHO): https://www.who.int/emergencies/diseases/novel-coronavirus-2019 Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (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 beyond2, 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 syndrome coronavirus (SARS-CoV) and Middle East respiratory 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-CoV5-8. SARS-CoV-2 belongs to the same β-coronavirus subgroup and it has genome similarity of about 80% and 50% with SARS-CoV and MERS-CoV, respectively9. SARS-CoV-2 is spread by respiratory droplets and direct contact (when body fluids of an infected person touch another person's eyes, nose or mouth, or an open cut, wound or abrasion). It should be noted that SARS-CoV-2 has been found in a laboratory environment to be viable on plastic and stainless-steel surfaces for up to 72 h, whereas on copper and cardboard it is viable for up to 24 h10. SARS-CoV-2 also remains viable and infectious in aerosols for hours, raising the possibility of airborne transmission. The Report of the World Health Organization (WHO)-China Joint Mission on Coronavirus Disease 2019 (COVID-19)11 estimated a high R0 (reproduction number) of 2–2.5. The latest report from WHO12, on April 10th, estimated the global mortality rate of COVID-19 to be 6.1%. However, other reports, which utilized appropriate adjustment for the case ascertainment rate and the time lag between onset of symptoms and death, suggested the mortality rate to be lower, at 1.4%13. Huang et al.14 first 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 clinical outcome of the patients. Subsequent studies with larger sample sizes have shown similar findings15, 16. The most common symptoms reported are fever (88.5%) and cough (68.6%)17. Myalgia or fatigue (35.8%), expectoration (28.2%) and dyspnea (21.9%) are also reported17. Diarrhea (4.8%) and nausea and vomiting (3.9%) are less common17. Breslin et al.18 observed similar COVID-19 severity in pregnant patients (86.0% mild disease, 9.3% severe disease and 4.7% critical disease) to that reported in non-pregnant patients16. On admission, ground-glass opacity is the most common radiologic finding on computed tomography (CT) of the chest (56.4%)16. 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 64.5% of patients on admission17. Elevated C-reactive protein and lactic dehydrogenase were observed in 44.3% and 28.3% of patients, respectively. Breslin et al. screened asymptomatic pregnant patients admitted to the labor ward, and found that 32.6% of them tested positive; however, 71.4% of these patients developed symptoms during admission or early postpartum18. Universal testing for COVID-19 remains a topic of debate and its need is determined mainly by local protocol and prevalence of the disease. A recent study from New York, USA, reported that a relatively large proportion (13.5%) of patients without any symptoms admitted for delivery tested positive for SARS-CoV-219. Of these patients, 10% developed fever before discharge from the hospital. This indicates the potential problem with triaging patients based merely on symptoms in areas with widespread community infection. Pregnancy is a physiological state that predisposes women to respiratory complications of viral infection. Due to the physiological changes in their immune and cardiopulmonary systems, pregnant women are more likely to develop severe illness after infection with respiratory viruses20. In 2009, pregnant women accounted for 1% of patients infected with influenza A subtype H1N1 virus, but they accounted for 5% of H1N1-related deaths21. In addition, SARS-CoV and MERS-CoV are both known to be responsible for severe complications during pregnancy, including the need for endotracheal intubation, admission to an intensive care unit (ICU), renal failure and death8, 22. The case fatality rate of SARS-CoV infection among pregnant women is up to 25%8. Currently, however, there is no evidence that pregnant women are more susceptible to SARS-CoV-2 or that those with COVID-19 are more prone to developing severe pneumonia18, 23-28. Over and above the impact of COVID-19 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 knowledge of other similar viral pulmonary infections, the following expert opinions are offered to guide clinical management. Case definitions are those included in the WHO's interim guidance, 'Global surveillance for COVID-19 caused by human infection with COVID-19 virus'29. Note: for confirmed asymptomatic cases, the period of contact is measured from 2 days before to 14 days after the date on which the sample that led to confirmation was taken. A person with laboratory confirmation of COVID-19, irrespective of clinical signs and symptoms. Evidence suggests that a proportion of transmissions occur from cases with no or mild symptoms that do not provoke healthcare-seeking behavior30. Under these circumstances, in areas in which local transmission occurs, an increasing number of cases without a defined chain of transmission is observed and a lower threshold for suspicion in patients with severe acute respiratory infection may be recommended by health authorities31. Any suspected case should be tested for SARS-CoV-2 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 SARS-CoV-2. The WHO recommends that, if possible, lower-respiratory-tract specimens, such as sputum, endotracheal aspirate or bronchoalveolar lavage, be collected for SARS-CoV-2 testing32. If patients do not have signs or symptoms of lower-respiratory-tract disease or specimen collection for lower-respiratory-tract disease is clinically indicated but collection is not possible, upper-respiratory-tract specimens of combined nasopharyngeal and oropharyngeal swabs should be collected. If initial testing is negative in a patient who is strongly suspected of having COVID-19, 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 aspirate). 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 compartments. When qRT-PCR analysis is negative for two consecutive tests, COVID-19 can be ruled out. The WHO has provided guidance on the rational use of PPE for COVID-1933. When conducting aerosol-generating procedures (e.g. tracheal intubation, non-invasive ventilation, cardiopulmonary resuscitation, manual ventilation before intubation), healthcare workers are advised to use respirators (e.g. fit-tested N95, FFP2 or equivalent standard) with their PPE33, 34. The Centers for Disease Control and Prevention (CDC) additionally considers procedures that are likely to induce coughing (e.g. sputum induction, collection of nasopharyngeal swabs and suctioning) as aerosol-generating procedures and CDC guidance includes the option of using a powered air-purifying respirator34, 35. Chest imaging, especially CT scan, is essential for evaluation of the clinical condition of a pregnant woman with COVID-1936-38. Fetal growth restriction (FGR), microcephaly and intellectual disability are the most common adverse effects from high-dose (> 610 mGy) radiation exposure39, 40. According to the American College of Radiology and American College of Obstetricians and Gynecologists, when a pregnant woman undergoes a single chest X-ray examination, 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 scan or CT pulmonary angiogram41-43. Chest CT scanning has high sensitivity (97%) for diagnosis of COVID-1938. In a pregnant woman with suspected COVID-19, a chest CT scan may be considered as a primary tool for the detection of COVID-19 in epidemic areas38. Informed consent should be acquired (shared decision-making) and a radiation shield applied over the gravid uterus. Because of the logistics involved in performing a CT scan on critically ill patients, and the need for thorough cleaning of the CT unit after imaging a COVID-19 patient, a portable chest X-ray is an acceptable alternative to a CT scan. A CT pulmonary angiogram is generally used in preference to a ventilation/perfusion scan on clinical suspicion of pulmonary embolus and should not be withheld during pregnancy. During the COVID-19 pandemic, it has been proposed that ultrasound examination of the lungs of a pregnant woman with suspected COVID-19 could be carried out at the same time as the obstetric scan, in order to minimize the risk of radiation as well as streamline the clinical assessment of these patients. This mode of lung imaging could also be considered when chest X-ray and CT scan are not available. However, management should be determined by the clinical features and severity of the disease, and not be based merely on diagnostic imaging. A practical guide on how to perform lung ultrasound examination in pregnant women with suspected COVID-19 was published recently44. In brief, the lung ultrasound scan can be performed using any type of machine and any type of transducer (including linear, convex and microconvex). Detailed guidance regarding cleaning of ultrasound equipment and transducers in the context of COVID-19 has been provided in the article 'ISUOG Safety Committee Position Statement on safe performance of obstetric and gynecological scans and equipment cleaning in context of COVID-19'45. On ultrasound, horizontal 'A-lines' are the hallmark of the normal lung. When the lung loses normal aeration, but is not completely consolidated, it generates different shapes and lengths of vertical artifacts, usually called 'B-lines'. When the density of the peripheral lung parenchyma is increased, ultrasound examination shows a white area (the so-called 'ultrasonographic white lung'), in which neither A-lines nor separated B-lines are visible. Consolidation appears as an irregular hypoechoic area, and pleural effusion appears anechoic. A videoclip and images demonstrating these findings can be found in the original article44. Following the obstetric abdominal ultrasound examination, with the patient in a supine position, the examiner can simply move the probe from the abdomen to the chest, scanning the anterior and lateral areas of the thorax. The examination should cover the whole pulmonary area, from basal to upper areas of the thorax. Four vertical lines (right mid-axillary line, right parasternal line, left parasternal line and left mid-axillary line) can be followed in order to perform a systematic examination. With the patient in a sitting or lateral position, the posterior paravertebral surface of the thorax should then be scanned, from basal to upper areas or along posterior-axillary lines according to the patient's position. Refer to Appendix 1. Triage of pregnant patients who potentially have COVID-19 is of great importance in order to reduce the risk of exposure for patients and healthcare workers alike23. Setting up a triage station outside the obstetric ward and outpatient clinic is essential, allowing for systematic and thorough screening (Appendix 2) for symptoms (e.g. fever, cough, sore throat) and risk factors (based on travel history, occupation, contact and cluster (TOCC)). Temperature should be checked. When concern is raised about a potential COVID-19 patient, i.e. due to symptoms and/or TOCC risk factors, a surgical facemask should be put on the patient and she should be separated from other patients, preferably in an isolated COVID-19 unit. Healthcare workers should don appropriate PPE for the management of pregnant women with suspected/probable/confirmed COVID-1933, 45, 46. Refer to Appendix 3. Suspected, probable and confirmed cases of COVID-19 should ideally be managed by designated tertiary hospitals with effective isolation facilities and protection equipment47. Suspected/probable cases should be treated in isolation and confirmed cases should be managed in a negative-pressure isolation room, when available; otherwise, designated COVID-19 units can help reduce spread by cohorting affected patients with dedicated staffing. Designated hospitals should set up a dedicated operating room and a neonatal isolation ward. Ideally, the operating room and neonatal isolation ward should have negative-pressure ventilation. When it is not possible to set up negative-pressure ventilation for operating rooms, it is advisable to discuss with the hospital engineer whether it is appropriate to switch off their positive-pressure ventilation. All attending medical staff should don PPE (fit-tested N95, FFP2 or equivalent-standard respirator, eye protection (goggles and/or face shield), disposable fluid-resistant and impermeable protective gown and double gloves) when providing care for confirmed cases of COVID-1933, 35, 48. 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 COVID-19 cases. Pregnant women with a mild clinical presentation may not initially require hospital admission, and home confinement can be considered, provided that this is possible logistically and that monitoring of the woman's condition can be ensured49. If negative-pressure isolation rooms are not available, patients should be isolated in single rooms, or grouped together once COVID-19 has been confirmed. For transfer of confirmed cases, the attending medical team should don PPE and keep themselves and their patient a minimum distance of 2 m, or 6 feet, from any individuals without PPE. When an inpatient has confirmed COVID-19, vigilant maternal monitoring (including oxygen saturation monitoring) is of paramount importance, allowing for rapid initiation of supportive care23. Although not yet validated in COVID-19 pregnant patients, a modified early obstetric warning score (MEOWS) can be used to enable early recognition of critical illness50, 51. An adapted MEOWS chart is provided in Appendix 4. When the maternal condition requires additional care, this should not be withheld due to pregnancy. Respiratory indications for transfer to an isolated negative-pressure room in the ICU include pulmonary edema, need for airway protection and necessity of mechanical ventilation50. Patients with hypoxemic respiratory failure should be admitted to the ICU as soon as possible. Multidisciplinary care (obstetricians, maternal–fetal-medicine subspecialists, intensivists, obstetric anesthetists, internal-medicine or respiratory physicians, midwives, virologists, microbiologists, neonatologists, infectious-disease specialists) is essential, particularly because some pregnancy-related diseases can cause findings similar to those of severe COVID-19 (e.g. pulmonary embolism) and because the physiologic changes of pregnancy may affect management (e.g. optimal maternal positioning, changes in respiratory physiology affecting appropriate ventilator settings). Particular attention should be paid to fluid and electrolyte balance. Symptoms should be treated, for example with antipyretic medicines. Maternal vital signs (preferably using MEOWS) and oxygen saturation level should be monitored vigilantly to minimize maternal hypoxia. Arterial blood-gas analysis should be conducted. Repeat chest imaging (when indicated) should be performed. Complete blood count should be evaluated regularly, with renal- and liver-function testing and coagulation testing. (1) The approach to symptomatic treatment and surveillance is the same as for suspected/probable cases. Conservative fluid administration is advised23, 52. Fluid balance should be evaluated regularly to minimize the risk of fluid overload53. Isotonic crystalloid fluid is the first choice of fluid to be administered. (2) Currently, there is no proven antiviral treatment for COVID-19 patients, although a number of drugs are being trialed therapeutically in patients with severe symptoms. Decisions regarding antiviral, antimalarial and antibiotic treatment should be undertaken in conjunction with local infectious-disease experts, and with the obstetrician providing advice on potential maternal or fetal effects of any treatment regimen. A summary of potential treatments, including hydroxychloroquine, lopinavir/ritonavir, interferon β-1b, tocilizumab, azithromycin and remdesivir, is provided in Appendix S2. (3) In non-pregnant COVID-19 patients, comorbidities such as hypertension or diabetes seem to increase the risk for progression to severe disease, with poorer clinical outcome54. Therefore, it is advisable to monitor closely pregnant patients with these comorbidities and to be aware of this increased risk. (1) The degree of severity of COVID-19 pneumonia is defined by the Infectious Diseases Society of America/American Thoracic Society guidelines for community-acquired pneumonia (Appendix S3)55, 56. (2) Severe pneumonia is associated with a high maternal and perinatal mortality rate; there is, therefore, a requirement for aggressive treatment, including supporting measures with hydration, oxygen therapy and chest physiotherapy. The case should be managed in a negative-pressure isolation room in the ICU, with the woman in a semi-recumbent or prone position, if feasible. Support should be provided by a multidisciplinary team57. (3) Antibacterial treatment: 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 management: in patients without septic shock, conservative fluid-management measures should be undertaken58. Excessive fluid can worsen hypoxemia in severe disease without shock23, 52. In patients with septic shock, fluid resuscitation and inotropes are required to maintain an average arterial pressure ≥ 65 mmHg and a lactate level < 2 mmol/L23, 50. The Hour-1 Surviving Sepsis Campaign bundle of care is a concise and practical approach to initial care for (suspected) sepsis59. This Bundle of Care is provided in Appendix S4. The WHO advises administration of 250–500 mL crystalloid intravenous fluid in the first 15–30 min, as a bolus23. (5) Oxygen therapy: supplemental oxygen should be used to maintain oxygen saturation > 94%23, 60; oxygen should be given promptly to patients with hypoxemia and/or shock, and the method of ventilation should be according to the patient's condition and following guidance from the intensivists and obstetric anesthetists23. Accelerated hypoxemia in pregnancy is possible, due to increased oxygen consumption and reduced functional residual capacity51. The intensivist should be aware of a higher likelihood of difficult intubation and greater risk of aspiration during pregnancy. (6) Medically indicated preterm delivery should be considered by the multidisciplinary team on a case-by-case basis. Early delivery may aid ventilation, allowing for prone ventilation if required. (7) Even in confirmed COVID-19 patients, other causes for maternal collapse should be examined51. It has been reported that viral pneumonia in pregnant women is associated with an increased risk of preterm birth, FGR and perinatal mortality61. Based on nationwide population-based data from Taiwan, it was demonstrated that pregnant women with viral pneumonia (n = 1462) had an increased risk of preterm birth, FGR and having a newborn with low birth weight and Apgar score < 7 at 5 min, compared with those without pneumonia (n = 7310)62. 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 presented after 24 weeks had preterm birth and two mothers recovered without delivery but their ongoing pregnancies were complicated by FGR8. Currently, there are limited data regarding the impact on the fetus of maternal SARS-CoV-2 infection. There is an apparent increase of iatrogenic preterm birth but not of spontaneous preterm birth; therefore, cervical-length screening is not recommended. Fever is common in COVID-19 patients. Previous data have demonstrated that maternal fever in early pregnancy can cause congenital structural abnormalities involving the neural tube, heart, kidney and other organs63-65. However, a study of 80 321 pregnant women reported that the rate of fever in early pregnancy was 10%, while the incidence of fetal malformation in this group was 3.7%66. 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))66. Previous studies have reported no evidence of congenital infection with SARS-CoV, and currently there are no data on the risk of congenital malformation when SARS-CoV-2 infection is acquired during the first or early second trimester of pregnancy67. If appropriate, giving advice via telephone or videoconferencing to patients with suspected/probable/confirmed COVID-19 can be considered53. When the patient has to be seen in hospital, early triage and isolation measures should be applied; all healthcare workers attending these patients should wear appropriate PPE33, 35. Management in a negative-pressure room is advised for confirmed cases. However, if this is not available, a dedicated single consultation room, from which any unnecessary equipment has been removed, is advised. Thorough disinfection between patients, according to local protocols, is essential, especially of high-touch surfaces45, 52. Hospital admission might be required for pregnant patients with suspected/probable/confirmed COVID-19, either because of the disease itself or for obstetric reasons. A separate (part of the) obstetric ward should be reserved for these patients, preferably with negative-pressure rooms for confirmed cases. This ward should use dedicated equipment, such as cardiotocography (CTG) or ultrasound machines45. This equipment should not be removed from the room/ward without appropriate disinfection. Prompt review by senior team members and, if necessary, multidisciplinary review, is advised for these patients53. Even if a patient is managed in an isolation ward, woman-centered and skilled care with psychosocial support remains important23. Additionally, thromboprophylaxis must be considered for all pregnant women who are managed as inpatients, especially in those with severe disease, unless delivery is imminent (within 12 h)23, 51, 53. The Royal College of Obstetricians and Gynaecologists advises prophylactic low-molecular-weight heparin for all pregnant women admitted with COVID-19, and this should also be considered in outpatient self-isolating patients on a case-by-case basis, according to risk factors53. However, if the patient decompensates rapidly, a thorough risk–benefit analysis should be made regarding the administration of thromboprophylaxis, due to safety concerns regarding its use in conjunction with neuraxial analgesia. Following maternal assessment, CTG for fetal heart-rate (FHR) monitoring, at an appropriate gestational age according to local practice, should be undertaken, as well as ultrasound assessment of fetal growth and amniotic fluid volume, with umbilical artery Doppler if necessary. In severe COVID-19 cases, the fetal scan can be performed once the patient is stabilized. All sonographers/sonologists should don appropriate PPE when undertaking the ultrasound scan35. Adequate cleaning of ultrasound equipment and transducers should be performed before further use45. Pregnant women with confirmed SARS-CoV-2 infection who are asymptomatic, or recovering from mild illness, should be monitored with 4-weekly ultrasound assessments of fetal growth and amniotic fluid volume, with umbilical artery Doppler if necessary68, 69. When the infection is acquired in the first or early second trimester of pregnancy, a detailed morphology scan at 18–23 weeks of gestation is indicated, and these pregnancies should be monitored carefully after recovery. The pregnancy should be managed according to the clinical findings, regardless of the timing of infection during pregnancy. All clinical visits for obstetric emergencies should be carried out in agreement with current local guidelines. All routine follow-up appointments should be postponed by 14 days or until positive test results (or two consecutive negative test results) are obtained. Recommendations on how to prioritize obstetric ultrasound services are provided in separate documents68, 70. Refer to Appendix 3. COVID-19 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, delivery should be conducted in a negative-pressure isolation room whenever possible. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the patient, gestational age and fetal condition53. In the event that an infected woman has spontaneous onset of labor with optimal progress, she can be allowed to deliver vaginally47. Continuous fetal and frequent maternal monitoring is essential in these patients. Therefore, for optimum care as well as for the protection of the medical team, given evidence of presence of the virus in feces and the inability of healthcare workers to use adequate PPE during the delivery, water birth should be avoided53, 71. Shortening the second stage by operative vaginal delivery can be considered, as active pushing while wearing a surgical mask may be difficult for the woman to achieve72. With respect to a pregnant woman without a diagnosis of COVID-19, but who might be a silent carrier of the virus, we urge caution regarding the practice of active pushing while wearing a surgical mask, as it is unclear if there is an increased r
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