perinatal and neonatal care in covid 19 dr ashwani k soodnrhmhp.gov.in/sites/default/files/files/3_...

Dr Ashwani K Sood

Perinatal and Neonatal care in COVID 19

• If a prenatal consultation is required, especially in births associated with extreme prematurity, outcomes based on gestational age, and available data should be discussed using phone/video to minimize exposure to healthcare providers.

• The possibility of infection in the husband should be considered and addressed as per the hospital’s visitation policy.

• The number of providers (obstetric and neonatal) in the delivery room should be minimized to limit exposure.

Prenatal Consult and Preparations for Delivery

Effect of COVID-19 on Pregnancy

• Pregnant women not more likely to contract the infection than general population

• Cases of COVID-19 pneumonia in pregnancy are milder with good recovery

• In other types of coronavirus infection (SARS, MERS), the risks to the mother appear to increase during the last trimester of pregnancy

• Case reports of preterm birth in women with COVID-19 but data insufficient

• Pregnant women with heart disease are at highest risk

• Higher risk of perinatal anxiety and depression, as well as psychological effects and domestic violence

• It remains unclear if vertical transmission of the virus occurs during pregnancy.

• Vertical transmission in Utero is rare including a report of nine pregnant infected women in China.

• Infants all tested negative for the virus.

• Currently, no data on• Vaginal secretions being positive for COVID-19 or

• Breast milk being positive for COVID-19

wh Chen H, Guo J, Wang C, et al. Clinical characteristics and Intra-uterinevertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020;395(10226):809–815

Transmission

• Recently, immunoglobulin (Ig)-M antibodies have been detected in newly born infants.

• Viral RNA has not been isolated.

• Disruption of the placental barrier in Placental abruption or maternal-fetal hemorrhage may potentially transmit the virus and/or IgM antibodies to the fetal circulation.

• Suggesting a possibility of vertical transmission.

• The risk of vertical transmission is unclear; transmission from family

members/providers to neonates is possible.

• Optimal personal-protective-equipment (airborne vs. droplet/contact precautions)

for providers is crucial to prevent transmission.

• Parents should be engaged in shared decision-making with options for rooming in,

skin-to-skin contact and breastfeeding.

What About Intrapartum Transmission of SARS-CoV-2

• Intrapartum transmission during passage through the birth canal requires fetal exposure to infectious virus. Is SARS-CoV-2 found in vaginal fluids?

• Study of 10 postmenopausal women in the ICU with severe COVID-19 (+ PCR, + CT scan), testing for SARS-CoV-2 in vaginal fluid (as well as blood and urine) with RT-PCR assay 17-40 days after diagnosis (while still in ICU):

• All samples were negative for the virus

• Data to date from pregnant women at delivery: • 6/6 samples negative for virus

• Potential exposure to virus after birth in delivery room is possible (but is really postnatal not intrapartum infection)

Effect on fetus

• Currently no data suggesting higher risk of miscarriage or early pregnancy loss in relation to COVID-19

• No conclusive evidence that SARS-CoV-2 is teratogenic; long term data awaited

Postnatal IPC

• Unknown whether new-born with COVID-19 are at increased risk for severe complications

• Transmission after birth via contact with infectious respiratory secretions is a concern

• Consider temporarily separating (separate rooms) the mother who is confirmed COVID-19 or suspect, from her baby until mother’s transmission-based precautions are discontinued

Vertical

infection:

Unlikely

Perinatal

infection:

Possible

Pregnant with confirmed COVID-19 infection

• The woman should inform the facility in advance of her arrival if possible, in order to allow time for preparation.

• Standard universal precautions to prevent contact with body fluids

• Use personal protective equipment (PPE) .

• Reception and triage should be in the same room as to be used for admission in labor and delivery.

Pregnant with confirmed COVID-19 infectionContd…

• Ideally, this should be a room with negative pressure (If not available, exhaust fans can be installed).

• Room free from any unnecessary items .

• Restriction on the number of attendants and non-essential staff into the room.

• Facilities for health care providers to remove and safely discard PPE at the exit of the room in which the patient is being cared for.

A Pregnant woman infected with COVID-19

• Mode of delivery should be guided by her obstetric assessment and her physiological stability (cardiorespiratory status and oxygenation).

• COVID-19 infection itself is not an indication for induction of labouror operative delivery.

• Continuous electronic fetal monitoring / Manual should be done during labor.

• Oxygen therapy should be titrated to maintain oxygen saturation of more than 94%.

Pre-surgery Preparation of Staff in Obstetric and Neonatal Division

• Crucial to plan for additional delivery rooms, personnel, to care for an obstetric patient with COVID-19 and her newborn.

• Make-shift delivery and operation rooms may need to be in place with proper PPE for the patients and health care providers in regions anticipating a surge.

• Simulations to handle delivery room situations are important to understand the logistics.

• Transition of care from the birthing room to NICU.

• Additional rooms for testing and safely discarding kits and disinfecting delivery and operation rooms should be in place.

Use of Antenatal Steroids

• The effect of administering antenatal steroids (ANS) in a COVID-19 mother for possible premature delivery remains Unknown

• The immunosuppressive effect of steroids could affect maternal response to infection in COVID-19.

• Variations in neonatal mortality following ANS in different countries and the plausible association with infection raises concern about its use.

• No evidence to support or refute ANS in mothers with COVID-19 with impending preterm delivery.

PPE and Care for COVID-19 positive births

• No clear guidelines at the moment

• Prudent to take full precautions

• What if status is unknown?

Recommendations for

neonatal resuscitation:

Recommendations for neonatal resuscitation

• Resuscitation of neonate can be done in a physically separate adjacent room earmarked for this purpose.

• If not feasible, the resuscitation warmer should be physically separated from the mother’s delivery area by a distance of at least 2 meters.

• A curtain can be used between the two areas to minimize opportunities for close contact.


• Minimum number of personnel should attend

(one person in low risk cases and two in high risk cases where extensive resuscitation may be anticipated)

• Wear a full set of personal protective equipment including N95 mask.


• The umbilical cord should be clamped promptly and skin to skin contact avoided.

• Neonatal resuscitation should follow standard guidelines. AAP-IAP NRP

• If positive-pressure ventilation is needed, self-inflating bag and mask may be preferred over T-piece resuscitator.

Symptomatic Neonates- COVID 19

• Sick Neonates and Neonates born to a mother with suspected or proven COVID-19 infection should be managed in separate isolation facility from other babies.

• Isolation Area should be separate from the NICU/SNCU with a transitional area in-between.

• If single rooms are not available, closed incubators (preferred) or radiant warmers could be placed in a common isolation ward for neonates.

• The neonatal beds should be at a distance of at least 1 meter from one another.

Presentation of three symptomatic Newborns


• Suspected COVID-19 cases and confirmed COVID-19 cases should ideally be managed in separate isolations.

• The access to isolation ward should be through dedicated lift or guarded stairs.

• Negative air borne isolation rooms are preferred for patients requiring aerosolization procedures (respiratory support, suction, nebulization)


• Negative pressure could also be created by 2-4 exhaust fans driving air outof the room.

• If room is air-conditioned, ensure 12 air changes/ hour and filtering ofexhaust air.

• These areas should not be a part of the central air-conditioning.


• The doctors, nursing and other support staff working in these isolation rooms should be separate.

• The staff should be provided with adequate supplies of PPE.

• The staff also needs to be trained for safe use and disposal of PPE.

• If the facilities of isolation intensive care are not available referred to State designated closest COVID – 19 hospital .


Respiratory support :

• NIPPV and High Flow Nasal Cannulas should preferably be avoided.

• Healthcare providers in NICU should practice contact and droplet isolation and wear N95 mask.

• The area providing respiratory support should be a negative air pressure area.


Specific Anti-COVID-19 treatment –

• Antivirals or chloroquine/hydroxychloroquine - is NOT recommended in symptomatic neonates with confirmed or suspected COVID-19.

• Use of adjunctive therapy such as systemic corticosteroids and IVIG is NOT recommended

Postnatal Workup and Care of the Neonate If the mother is positive for COVID -19

Mother positive for COVID :

• Infant should be tested at or beyond 24 hours after birth.

• Separate swabs of the nasopharynx, oropharynx, and rectum are recommended.

• Second test 24 hours later may be valuable for confirmation.

• To date, the literature reports four neonates who have tested positive for COVID-19 at 36 hours of life

Admit in Isolation room. Close monitoring and supportive care for high-risk or sick babies

Trace mother result

Mother result- Negative

If the neonate requires

intensive care, continue the supportive

management

Asymptomatic and stable

Discharge the baby with follow up

Mother result- Positive

Collect the oro/nasopharyngeal swab for the neonate at birth

Trace result-

Neonate

Neonate result is –ve

Symptomatic and unstable, continue the supportive

management

Repeat 2nd sample at 48 to 78 hours

Asymptomatic and stable

Discharge once negative for 2

consecutive samples with follow up

Neonate result is +ve

Asymptomatic and stable neonate

Repeat the sample every 48 hours until turns

negative

Discharge once negative for 2 consecutive samples with follow up

Symptomatic and unstable,

continue the supportive measures

Repeat the sample every 48- 72 hours until result

comes -ve

DECISION TREEfor breastfeeding in context of COVID-19:

Guidance for health care and community settings

• Some viral infections such as CMV and HIV are transmitted through breast milk. With present knowledge , there is no evidence that COVID-19 is secreted in breast milk.

• The CDC states that “we do not know whether mothers with COVID-19 can transmit the virus via breast milk”.

• It is reassuring that in six Chinese cases tested, breastmilk was negative for COVID-19; however, given the small number of cases, this evidence should be interpreted with caution.

• The main risk for infants of breastfeeding is the close contact with the mother, who is also likely to share infective airborne droplets.

• As breast milk is the best source of nutrition and immunity for the infant, UNFPA encourages it.

• In the light of the current evidence, we advise that the benefits of breastfeeding outweigh any potential risks of transmission of the virus through breast milk.

• The risks and benefits of breastfeeding, including the risk of holding the baby in close proximity to the mother, should be discussed with her.

Breastfeeding and the COVID-19 infected mother

DECISION TREEfor breastfeeding in context of COVID-19:

Guidance for health care and community settingsIs mother a suspected or

confirmed case of (COVID-19?

Is mother well enoughto Breastfeed?

Is mother able toexpress breastmilk

(including with help)?

• Mother should wear a medical mask during feeding

• If a medical mask is unavailable, advise mother to:

• Sneeze or cough into a tissue and Immediately dispose it & wash hands

• Chest should be washed if she has been coughing on it

• Breast does not need to be washed before every feeding.

Feed mothersexpressed milk

to the baby

Revert to direct breastfeeding when

mother is well enough to breastfeed

NO

NO

NO

Yes

Yes

Yes

• Support mother to breastfeed• For newborns, initiate breastfeeding

within first hour after delivery and practice skin-to-skin care at soon as possible

• For infants support exclusive breastfeeding

• For infants and young children >6 months, continue breastfeeding with safe and health complementary foods

• Do not separate mother and baby

• Advise mother to• Wash hands frequently with soap

and water or use alcohol based hand rub before touching the baby

• Regularly dean and disinfect surfaces that she has touched

Is human milk available from a donor human

milk bank?

feed donor human milk to the baby until the mother recovers

Is wet-nursing culturally acceptable and can a

safe wet nurse be identified?

Facilitate wet nursing of The baby until the mother

recovers

feed Infant formula milk to the baby until the mother recovers

Is mother willing tobreastfeed after recovery?

Assist mother withRe-lactation when she is well

enough to breastfeed

Continue alternative modes of feeding the

baby

NO

NO

NO

Yes

Yes

Yes

• Support mother to breastfeed• For newborns, initiate breastfeeding

within first hour after delivery and practice skin-to-skin care at toon as possible

• For infants support exclusive breastfeeding

• For infants and young children >b months, continue breastfeeding with safe and health complementary foods

• Do not separate mother and baby

• Advise mother to• Wash hands frequently with soap and

water or use alcohol based hand rub before touching the baby

• Regularly clean and disinfect surfaces that she has touched

Helpline no. 104 and 1075

IMMUNIZATION

• Follow routine immunization policy in healthy neonates born to mothers with suspected/proven COVID-19 infection.

• In neonates with suspected/proven infection, vaccination should be completed before discharge from the hospital as per existing policy.

In this cohort, 3 of 33 infants (9%) presented with early- onset SARS-CoV-2 infection. Consistent with previous studies, the clinical symptoms from 33 neonates with or at risk of COVID-19 were mild and outcomes were favorable.

Although children are less likely than adults to have severe Covid-19, this case illustrates that it can occur and can be successfully managed with standard PICU protocols.

The one exception to the standard protocol was that noninvasive mechanical ventilation was not attempted, since Covid-19 was suspected.

Discharge policy

• Stable neonates exposed to COVID-19 and being roomed-in with their mothers may be discharged at time of mothers’ discharge. (Weak recommendation)

• Stable neonates in whom rooming-in is not possible because of the sickness in the mother and are being cared by a trained family member may be discharged from the facility by 24-48 hours of age.(W. Recommendation)

• Early discharge to home may be followed by a telephonic follow-up or home visit by a

designated healthcare worker.

• Mothers and family members should be counselled regarding the danger signs and

advised to report back to the facility if the neonate develops any of the danger signs.

• If the neonate develops any danger signs or becomes unwell during home isolation,

he/she should be taken to a designated hospital facility for assessment as well as

COVID-19 testing (if indicated).

• Mothers and family members should perform hand hygiene frequently including before

and after touching and feeding the baby.

• Mothers should practice respiratory hygiene and wear a mask while breastfeeding and

providing other care to the baby; they should routinely clean and disinfect all the

surfaces.

• Healthcare professional working in any childbirth or neonatal area

should report to their supervisor if they have respiratory or other

symptoms suggestive of COVID-19 infection.

• Such healthcare professional should not be put on clinical duty and

should be replaced by a healthy healthcare professional to maintain

appropriate patient-provider ratio.

• Healthcare professional directly involved in the care of patients with

suspect/proven COVID-19 infection may consider taking HCQ

prophylaxis as advised by GOI, on medical prescription.

• However, this advisory is based on low-quality evidence and may change in near future.

Considerations for temporary separation

• Separate isolation room should be available for the infant while they remain a suspect

• If co-location (“rooming in”) of the new-born with his/her ill mother in the same hospital room occurs, facilities should consider implementing measures to reduce exposure of the new-born

• Consider engineering controls like physical barriers (e.g. curtain between the mother and new-born) and keeping the new-born at least 1 metre away from the ill mother

• If no other healthy adult is present in the room to care for the new-born, a mother who has confirmed COVID-19 or is a suspect should put on a facemask and practice hand hygiene before each feeding or other close contact with her new-born

• Facemask should remain in place during contact with the new-born

COVID-19 risk communication

• COVID-19 virus is creating fear

• Communication needs to be direct, transparent & consistent

• Potential of panic is very high

• Positive tone, a sense of reassurance as 81% of cases are mild

• Prevention is crucial, provides meaningful rationale

• Enhance understanding of risks/risk factors among public and high risk groups

• Everyone has a role to play

Key Points

• Chest compressions, suctioning, intubation, and positive pressure ventilation are aerosol-generating procedures.

• Healthcare workers should don appropriate personal protective equipment (PPE) prior to participating in resuscitation efforts.

• Limit the number of providers present during the resuscitation.

• Consider deploying a mechanical CPR device.

• Prioritize airway management techniques that reduce aerosol generation.

• Consider early intubation with a cuffed endotracheal tube, performed by the provider most likely to succeed. Video laryngoscopy may reduce exposure.

• If bag-valve-mask ventilation is used, there must be a tight seal throughout inhalation and exhalation.

• Pause compressions for intubation.

• After placing an advanced airway, minimize disconnections to reduce aerosol release.

• Place a HEPA filter on exhalation ports of bag-valve-mask or ventilator.

• Consider appropriateness of initiating and continuing resuscitation efforts. Termination of resuscitation by Emergency Medical Services policies should be instituted/reviewed.

• If an intubated patient suffers cardiac arrest, consider leaving the patient on the mechanical ventilator with settings to allow asynchronous ventilation.

• In neonates, suctioning is not indicated for uncomplicated deliveries, even if meconium-stained amniotic fluid is present

• If possible, uninfected individuals >60 years of age or with comorbid conditions should not care for these infants.

• If symptomatic, baby needs NICU care.

• These guidelines are subject to change with emerging evidence.

Disinfection of Surfaces

Childbirth/neonatal care areas:

1. Wear personal protective equipment before disinfecting

2. If equipment or surface is visibly soiled first clean with soap and water solution or soaked cloth as appropriate before applying the disinfectant

3. 0.5% sodium hypochlorite (equivalent to 5000 ppm) can be used to disinfect large surfaces like floors and walls at least once per shift and for cleaning after a patient is transferred out of the area.

Disinfection of Surfaces

4. 70% ethyl alcohol can be used to disinfect small areas between uses, such as reusable dedicated equipment

5. Hydrogen peroxide (dilute 100 ml of H2O2 10% solution with 900 ml of distilled water) used for :

6. Cleaning of incubators, open care systems, infusion pumps, weighing scales, standby equipment-ventilators, monitors, phototherapy units, and shelves.

7. Use H2O2 only when equipment is not being used for the patient. Contact period of 1 hour is needed for efficacy of H2O2

Thank you

perinatal and neonatal care in covid 19 dr ashwani k soodnrhmhp.gov.in/sites/default/files/files/3_...

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