Dr. Haiyi Liu, Obstetrics Dept

Dr. Ling Feng, Head of Obstetrics Dept

Dr. Zhihui Rong, Neonatal ICU Dept

Dr. Ling Chen, Head of Neonatal ICU Dept

Wuhan Tongji Hospital, Tongji Medical College, Huazhong Univ. of Science & Technology

Pregnancy and Neonatal Care

during COVID-19 Wuhan United “Living Through A Pandemic” Series 6

Organized by: Wuhan Tongji Hospital Tongji Medical College, UC Davis Health

MEDICAL DISCLAIMER

THIS PRESENTATION IS FOR EDUCATIONAL AND INFORMATIONAL PURPOSES ONLY AND MAY NOT BE CONSTRUED AS MEDICAL ADVICE. THE INFORMATION IS NOT INTENDED TO REPLACE MEDICAL ADVICE OFFERED BY PHYSICIANS.

Co-hosted by

Dr. Herman Hedriana, Professor of Clinical OBGY

Head of Maternal-Fetal Medicine, UC Davis Health

Dr. Leep Koon Teo, MD, Neonatologist

St. Joseph’s/Candler Hospital, Savannah, GA

Pregnancy and Neonatal Care

during COVID-19 Wuhan United “Living Through A Pandemic” Series 6

MEDICAL DISCLAIMER

THIS PRESENTATION IS FOR EDUCATIONAL AND INFORMATIONAL PURPOSES ONLY AND MAY NOT BE CONSTRUED AS MEDICAL ADVICE. THE INFORMATION IS NOT INTENDED TO REPLACE MEDICAL ADVICE OFFERED BY PHYSICIANS.

Organized by: Wuhan Tongji Hospital Tongji Medical College, UC Davis Health

• Case study of three pregnant women with COVID-19

• Guidance on diagnosis and treatment of pregnant women with COVID-19

• Flow chart of the treatment for pregnant patients during COVID-19

• The prognosis of the pregnant patients with COVID-19

• Detection and more evidence of COVID-19 by PCR

• Specific antibodies in the early days of life

• Early, middle and late stage of pregnancy

• Continuous monitoring of specific antibodies

• Dialogue on “Pregnancy and Neonatal Care during COVID-19”

• Q&A

Contents

Pregnancy Care during COVID-19

Dr. Haiyi Liu

Obstetrics Dept, Wuhan Tongji Hospital

Dr. Haiyi Liu has been working in the Obstetrics and Gynecology department of WuhanTongji Hospital

for 20 years, and she participated in the treatment of pregnant women with COVID-19 since the

beginning of COVID-19 in Wuhan.

Case 1---2020.1.23

2020.1.23

MORINIG

• CS of scar uterus

• No symptom before C.S

2020.1.23

NIGHT

• Fever

• CT positive

2020.2.6

2020.2.20 • Discharge

COVID-19

positive

General ward

Isolation ward

TAKE BABY

HOME

Isolation

Hotel

2020-2-17

2020-2-4

2020-1-24

Case 2---2020.2.4

2020.2.2

• G40+3-41w Fever 4 days

• cough and fatigue

• 2020/2/2 CT positive

• COVID-19 ?

2020.2.3• C.S(G41+2W)

• fever for two days after the C.S

2019.2.25 discharge

Exposure

history--taxi?

Isolation

ward

Isolation

operating

room with

negative

pressure

Isolation

Hotel

2020-2-2

Fever Clinic

BABY in the

NICU until

1month old

Husband: go to

another hospital

isolation ward

2020-2-182020-2-12

Disease course of the mother

2020-2-7

Case 3---2020.2.9

2020.2.5

• multipara

• G39w, with irregular uterine contraction

• Cough 10 days, without fever

• CT/COVID (+)

2020.2.9

• In spontaneous labor

• Succesfulvaginal delivery

2020.2.28 • Discharge

Isolation ward

Isolation

operating

room with

negative

pressure

BABY to

the NICU

2020-2-20

2020-2-5

Isolation

Hotel

Trial Edition 1-4

1POINT

Suspected Cases

Confirmed Cases

2

Trial Edition 5

POINT

Suspected Cases

Confirmed Cases

Hubei Province:

+clinically diagnosed cases

Trial Edition 6-7

3POINT

Suspected Cases

Confirmed Cases

COVID-19---how to make a diagnosis

《The Diagnosis and Treatment Scheme for COVID-19》( Trial Edition1-7)

— the National Health Commission of the People’s Republic of China

Feb 4, 2020 ～ Feb 19, 2020 ～Jan 15, 2020 ～

•Travel history or

residence history

•Contact history

•Clustering occurrence

Epidemiological history

•Symptom

•Blood cells

•imaging characteristics

Clinical manifestations

Trial edition 7

The Suspected Cases

1 + 1

or 0 + 2

01 RT-PCR

02 Virus gene sequencing

03 COVID-19 IgM and IgG

The

Suspected

Cases

OR

OR

Trial edition 7

The Confirmed Cases

Flow Chart of Treatment

Obstetric

monitoring:

•Fetal

movement

•Fetal heart

monitoring

•Ultrasound

Designated

hospital

A single

room

Breastfeed is not

recommended

Epidemiological history Clinical manifestations

Suspected cases

Comfirmed cases

MDT:

Obstetrics ,

Neonatology,

Infections,

pneumology,

anesthesiology

department,ICU,

operating room

isolation

ward :

Antenatal

Examination

or delivery

terminate

pregnancy

Breastfeed is not

recommended

Neonatal

Isolation: at

least 14

days

Severe Cases:

ICU

No fever≥3d; respiratory symptoms are improved; Pulmonary lesions are significant absorbed; Nucleic

acid is negative twice(The interval≥1d)

disisolation

etiological examination

Our achievement

442

(CONFIRMED CASES 21

(SUSPECTED CASES 21

Delivery mother 379

baby

Discharged from Obstetric Department

NONE OF THE DOCTOR OR

THE NURSE WAS INFECTED

BY THE COVID-19

Nan Yu*, Wei Li ,…….Ling Feng, Jianli WU. Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study. Lancet Infect Dis 2020,March 24, 2020 https://doi.org/10.1016/S1473-3099(20)30176-6

• Findings from zhang' cases suggest that there is currently

no evidence for intrauterine infection caused by vertical

transmission in women who develop COVID-19 pneumonia

in late pregnancy

• Two articles reported in JAMA present 3 neonates may

have been infected with COVID-19 in utero for elevated

IgM antibody values in blood drawn from the neonates

following birth

• We also report COVID-19 negativity in amniotic fluid from

two pregnant women who were diagnosed with COVID-19

in the early stage of pregnancy

1. Zeng H, Xu C, Fan J, Tang Y, Deng Q, Zhang W, Long X. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA. 2020 Mar 26. doi:

10.1001/jama.2020.4861. [Epub ahead of print]

2. Dong L, Tian J, He S, Zhu C, Wang J, Liu C, Yang J. Possible Vertical Transmission of COVID-19 From an Infected Mother to Her Newborn. JAMA. 2020

Mar 26. doi: 10.1001/jama.2020.4621. [Epub ahead of print]

3. Yu N, Li W, Kang Q, Zeng W, Feng L, Wu J. No COVID-19 detected in amniotic fluid in mid-pregnancy. Lancet Infect Dis 2020. Published Online.

April 22, 2020. https://doi. org/10.1016/ S1473-3099(20)30320-0.

Intrauterine vertical transmission potential of COVID-19

infection

Mother and Infant Vertical Transmission

Dr. Zhihui Rong has worked in neonatal ICU and participated in the management of neonates born to

mothers with COVID-19 since early January 2020

Dr. Zhihui Rong

Neonatal ICU Dept, Wuhan Tongji Hospital

Dr. Ling Chen

Director of NICU, Wuhan Tongji Hospital

Dr. Chen has worked as the head of neonatal intensive care unit of Tongji

Hospital, and she participated the creation of Tongji Hospital “Guidance of

diagnosis and treatment of COVID-19 in Pregnant women and neonates” at

the beginning of COVID-19 in Wuhan.

Mother-infant vertical transmission

Contents:

* Evidences that we know:

1. Detection of COVID-19 by PCR…

2. Specific antibodies in the early days of life…

* What do we need to explore?

1. Mother infected at different stages of pregnancy, infant

outcome?

2. Follow up studies on Specific antibodies

Evidences that we know

● Time between mothers onset of symptom to delivery: 8h-21d

● Prenatal medication: no steroid use, 6/19 with antivirus

medication

● All delivery occurred in a negative-pressure isolation room;

neonates were immediately separated from their mothers and

transferred to NICU

● There were 13 male and 6 female infants, GA 38.6±1.5w,

BWT 3293±425g

● None of the neonates need any respiratory support ; None of

the neonates developed clinical, radiologic, hematologic, or

biochemical evidence of COVID-19

Mother-infant infection

● Intrauterine vertical transmission:

● During delivery: contaminant with maternal blood or

secretion

● Postnatal infection, especially during breastfeeding

and closely contact with infected patients

● Intrauterine vertical transmission:

1. Angiotensin-converting enzyme-2 receptors have very low expression

in the placenta

Reproductive and Developmental Medicine, 2020. DOI: 10.4103/2096-2924.278679

2. The placenta of infected mother lacked the morphological changes

related to virus infection, and SARSCoV-2 nucleic acid in placenta was

undetectable

Chen. Chinese Journal of Pathology, 2020,49. DOI: 10.3760/cma.j.cn112151-20200225-00138

Intrauterine vertical transmission during the late pregnancy is likely

impossible!

However, it remains unclear if the maternal

viral charge or timing of COVID-19 infection

may influence the transmission???

Evidences that we know

Early onset of COVID-19 infection in neonates

Title of the articles 1st author Onset of

disease

Outcome

s

Clinical features and obstetric and neonatal

outcomes of pregnant patients with COVID-

19 in Wuhan

Wu JL + PCR@36h Well

Neonatal Early-Onset Infection With COVID-19 In 33

Neonates Born to Mothers With COVID-19 Zeng LK +PCR D2 and

D4, - on d6 and

7

Well

Antibodies in Infants Born to Mothers

With COVID-19 Pneumonia

Hui Zeng 2/6 with

increased IgM

on d0

Well

Possible Vertical Transmission of COVID-19

From an Infected Mother to Her Newborn

Lan Dong Elevated IgM at

D0 and

decrease to

normal on d14

Well

● Specific antibody (IgM and IgG)

● Intrauterine vertical transmission:

● During delivery: maternal blood or secretion

1. Delivery occurred in an isolated operating room

2. All the surgeons, nurses, and other staffs in the operating

room were wearing tertiary protective clothing

3. Most of the pregnant women delivered their infants by

cesarean section and only one by vaginal delivery

4. A neonatal transport team specializing in infection control

performed the transfer to NICU.

● Intrauterine vertical transmission:

● During delivery: maternal blood or secretion

● Postnatal infection, especially during breastfeeding and closely

contact

1. The mother and newborn need to be isolated separately until both are

cleared

2. Level II protective clothing for all medical staffs was required

3. All the neonates were fed with formula (breastmilk?)

4. Monitoring included vital signs, oxygen saturation, blood glucose,

intestinal motility and neonatal jaundice

5. Medical and other equipment for these neonates were designated and not

shared with other patients.

Evidences that we know

late onset of COVID-19 infection in neonates

Title of the articles 1st author Onset of

disease

Outcome

s

First case of neonate with COVID-19 in

China

Zeng LK D17 Well

Novel coronavirus in a 15-day-

old neonate with clinical signs of sepsis

Kamali

A(Iran)

D15 Well

COVID-19 infection with gastrointestinal

symptoms as the first manifestation

Zeng LK D19 Well

Sequential analysis of viral load in a

neonate and her mother infected with

COVID-19

Han

MS(Korea)

D27 Well

Until now, 40+ cases born to COVID-19 mothers---zero neonate

infection!

Summary what we already know:

● COVID-19 PCR test is the golden standard,

Elevated IgM only once can not make the diagnosis

● Intrauterine vertical transmission is unlikely

possible happened if the mother infected during

late pregnancy

● Infection during delivery and postnatally infection

are unavoidable, isolation infant with infected

mother or other caregivers is strongly

recommended

● Pumping the Breast and feed the baby by

breastmilk maybe an option!

1. Follow up studies: Elevated IgM once can not make the

diagnosis , but Continuous monitoring Specific antibodies

maybe helpful to verify intrauterine transmission

2. More evidence of COVID-19 needed: SARSCoV-2 nucleic

acid detection of different stages of breastmilk, feces of the

newborns.

3. Maternal viral charge or timing of COVID-19 infection may

influence the transmission : lack of data to support the

intrauterine transmission if the mother infected during early

and middle stage of pregnancy

What do we need to explore?

Dialogue on “Pregnancy and Neonatal Care during COVID-19”

Dr. Ling Feng has worked as the head of Obstetrics dept of Tongji Hospital. She participated

in the creation of Tongji Hospital “Guidance of diagnosis and treatment of COVID-19 in

Pregnant women and neonates” at the beginning of COVID-19 in Wuhan. She is the chief

editor of ‘Obstetric Protection Manual for COVID-19’ (People's Medical Publishing House),

and authors of two papers about the prognosis and prenatal diagnosis of the pregnant

patients with COVID-19 on the Lancet Infectious Disease.

Dr. Ling Feng

Head of Obstetrics Dept, Wuhan Tongji Hospital

Dr. Ling Chen

Head of Neonatal ICU Dept, Wuhan Tongji Hospital

Dr. Ling Chen has worked as the head of neonatal ICU of Tongji Hospital, and she

participated in the creation of Tongji Hospital “Guidance of diagnosis and treatment of

COVID-19 in Pregnant women and neonates” at the beginning of COVID-19 in Wuhan.

Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College of HUST

Ling Feng

May 2nd, 2020

Pregnancy and Neonatal Care

during COVID-19

A1:

Fever, cough and other respiratory

symptoms, general fatigue

Q1：

What was the first signs when you realized

you were dealing with a novel viral infection

in pregnancy?

Q2：

Pneumonia is the most common morbid

non-obstetric infection in pregnancy,

was this the same with COVID-19?

A2:

Yes.

Q3：

What PPE do you use for vaginal

delivery? Cesarean section?

Intrapartum/ Intraoperative protection:

① Confirmed or suspected case: third-level protection

②Emergencies or severe obstetric conditions with no time to

screen for COVID-19: third-level protection

③Pregnant women without COVID-19:Follow the routine

surgery protocol. It is recommended to wear goggles.

①Third-level protection: medical protective masks, goggles / face

shields, disposable hats, protective clothing, isolation clothing, shoe

covers, boots, etc.

➢Given that amniotic fluid and blood splatters during labor and

delivery, goggles / face shields and waterproof long-legged boots

are important.

②Protection needs to run through the entire process of childbirth

and surgery, and pay attention to strict aseptic operation.

③Pregnant women need to wear surgical masks throughout the

entire process of childbirth and surgery.

Intrapartum/ Intraoperative protection:

Timing of termination of pregnancy:

➢Before 34 weeks of gestation with mild or moderate infection, and no other indications of termination of pregnancy: Prolong the gestational weeks under strict monitoring and follow-up. There is no evidence for early termination of pregnancy.

➢The timing of termination of pregnancy should be made taking all the factors into account, including the severity of the disease, gestation and fetal intrauterine condition.

Timing of termination of pregnancy:

➢It is recommended to terminate pregnancy in the following situations:

①There are obstetric indications to terminate pregnancy.

②For pregnant women diagnosed with COVID-19, terminate the pregnancy if the conditions do not improve after treatment.

③ For pregnant women with severe or critical conditions of COVID-19: : Early termination of pregnancy must be considered to protect the mother's safety, regardless of the number of gestational weeks.

delivery method

➢ Delivery method for pregnant women with confirmed COVID-19 should be decided upon obstetric indications and comprehensive evaluation of disease severity.

➢ loosen the restriction of cesarean section ：• Avoid aggravation of the disease: decrease of resistance

due to physical exhaustion during labor;• Be beneficial to to infection control: maternal

hyperventilation, amniotic fluid, vaginal bleeding, vaginal discharge and so on during prolonged labor;

• In case of transition to an emergency cesarean section, infection control measures are difficult to be adopted quickly and effectively. Increasing the risk of spreading the virus ang medical staff getting infected.

Q4：Did you ever do for universal testing for all Obstetric admissions after recognizing the possible complications after delivery?

A4:ALL hospitalized pregnant women undergo four screening tests: blood routine, nucleic acid test, chest CT and IgG / IgM of novel coronavirus.

Q5:Was rapid testing available? What was the turn around time?

A5： The result of IgG / IgM antibody reports back in 35 minutes. The result of nucleic acid test report back in 3 hours.

Q6：What is the role of SARS-CoV-2 PCR relative to IgM & IgG in terms of timeline?

Q7：1.What is the clearance of SARS-CoV-2 RNA in maternal blood? In amniotic fluid?A:Clearance rate is 100% in 2-7 days. There is no SARS-CoV-2 RNA found in amniotic fluid.

2.Have you tried to retrieve SARS-CoV-2 from spun down amniotic fluid or cord blood (not umbilical cord sample)?A：All the results reported back as negative.

Management at delivery: Cut off the umbilical cord as soon as possible and move the newborn to the neonatal resuscitation table (in another room) .

Q & A

Thank You !

Contact: info@wuhanunited.org

Organized by

Wuhan Tongji Hospital, Tongji Medical College, HUST

UC Davis Health

Wuhan United “Living Through A Pandemic” Series 6