Module 8 COVID-19 FAQs for Obstetrician-Gynecologists
Return to Work After SARS-CoV-2 Infection or Exposure
The CDC provides detailed guidelines for work restrictions for healthcare personnel (HCP) with SARS-CoV-2 exposures, taking into account exposure risk, PPE use, and vaccination status to ensure healthcare safety.
The CDC also offers specific recommendations for work restrictions for HCP with SARS-CoV-2 infection and exposures, balancing the need to mitigate staffing shortages with infection control.
Clinicians should regularly review the frequently updated CDC guidelines, considering varying local circumstances and collaborating closely with their facilities to implement appropriate return-to-work strategies.
After any restrictions, HCP returning to work should:
Always wear a face mask for source control in the healthcare facility until symptoms resolve or return to baseline, adhering to the facility's universal source control policy.
Note that a residual nonproductive cough may persist for weeks after illness resolution but should not prevent return to work if other criteria are met.
A face mask for source control does not replace the necessity of an N95 or higher-level respirator (or other recommended PPE) when indicated for specific procedures or high-risk situations.
Self-monitor vigilantly for symptoms, seeking prompt reevaluation if respiratory symptoms recur or worsen to prevent potential workplace transmission.
Personal Protective Equipment (PPE) for Healthcare Professionals
Maintaining comprehensive infection control strategies, including diligent hand hygiene and environmental disinfection, is critical in all healthcare settings, regardless of vaccination rates, to minimize the risk of transmission.
Obstetric care clinicians should consistently wear adequate and appropriate PPE, including gloves, gowns, eye protection, and respiratory protection, when caring for all patients with suspected or confirmed COVID-19, ensuring personal safety and preventing nosocomial spread.
The CDC provides detailed recommendations for PPE selection and use and offers strategies to optimize PPE supply, including extended use and reuse protocols, on its website to address potential shortages.
Treatment Options for Pregnant Individuals
General Considerations
Comprehensive treatment options for COVID-19, including antiviral medications and supportive care, are available for use in pregnancy, and decisions should be made in consultation with maternal-fetal medicine specialists.
The NIH and ACOG strongly advise against withholding treatment options for pregnant and lactating individuals solely because of pregnancy or lactation, emphasizing the importance of individualized risk-benefit assessment.
Outpatient Treatment
The preferred outpatient treatment is Ritonavir-Boosted Nirmatrelvir (Paxlovid), which has demonstrated efficacy in reducing the risk of hospitalization and death in high-risk individuals.
Paxlovid can be safely administered to non-hospitalized pregnant and lactating patients, based on available data and expert consensus, to mitigate disease progression.
The recommended dosage for Paxlovid is mg nirmatrelvir (two mg tablets) with mg ritonavir (one mg tablet), all taken together twice daily for 5 days, as per the FDA package insert and treatment guidelines.
Treatment should be initiated promptly in patients who test positive for COVID-19 or are highly suspected to be positive based on exposure and symptoms, particularly in those with risk factors for severe disease.
Obstetrician-gynecologists must thoroughly assess the patient for any contraindications to Paxlovid and meticulously review any possible drug-drug interactions before prescribing, consulting with pharmacists as needed.
If there is suspected or confirmed co-infection with influenza and COVID-19, both oseltamivir and Paxlovid should be prescribed concurrently and can be taken together without significant drug interactions.
There are no clinically significant drug-drug interactions between the antiviral agents or immunomodulators used to prevent or treat COVID-19 and the antiviral agents used to treat influenza, simplifying combination therapy.
Inpatient Treatment
A range of treatment options is available for hospitalized pregnant patients, including antiviral medications, immunomodulators, and supportive care, tailored to disease severity and individual patient factors.
Specific recommendations for preferred treatment options for hospitalized individuals vary by disease severity, comorbidities, and gestational age, requiring a multidisciplinary approach to management.
The NIH provides detailed guidance on these options in their Treatment Considerations for Pregnancy and Lactation, offering algorithms and recommendations for various clinical scenarios.
Discontinuation of Transmission-Based Precautions
According to CDC's comprehensive guidance, discontinuation of transmission-based precautions in the health care setting for an individual with confirmed COVID-19 should be determined using a symptom-based strategy, ensuring safety for both patients and staff.
The specific time period used depends on the patient's severity of illness and whether they are severely immunocompromised, with longer durations required for those with persistent symptoms or weakened immune systems.
Meeting strict criteria for discontinuation of transmission-based precautions is not necessarily a prerequisite for discharge from a healthcare facility, enabling appropriate outpatient management when feasible.
Patients who are discharged home for required isolation or who are treated as outpatients with a diagnosis of COVID-19 should strictly adhere to the detailed discontinuation of isolation precautions guidance provided by the CDC, preventing community spread.
Recommendations regarding discontinuation of transmission-based precautions may continue to evolve based on emerging scientific evidence and viral variants, necessitating ongoing vigilance and adaptation of protocols.
Increased Risk of Severe Morbidity and Mortality for Pregnant Individuals
Pregnant patients with symptomatic COVID-19 infection, when compared to uninfected pregnant patients, face an increased risk of:
Maternal death, highlighting the vulnerability of this population
Admission to the ICU, requiring intensive medical management
Requiring mechanical ventilation, indicating severe respiratory compromise
Cesarean delivery, potentially due to maternal or fetal distress
Preeclampsia or eclampsia, posing risks to both mother and baby
Thromboembolic disease, emphasizing the hypercoagulable state associated with both pregnancy and COVID-19 (Smith 2023)
Pregnant patients with moderate or severe COVID-19 infection had a significantly increased risk of a composite outcome of maternal mortality or serious morbidity from obstetric complications when compared to pregnant individuals without COVID-19 infection (Metz 2022).
Symptomatic pregnant individuals with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers, underscoring the importance of preventive measures (Ellington MMWR 2020, Collin 2020, Delahoy MMWR 2020, Khan 2021).
The CDC explicitly includes pregnant and recently pregnant individuals in its increased risk category for severe COVID-19 illness, emphasizing the need for prioritization in vaccination and treatment efforts.
Pregnant and recently pregnant patients with comorbidities such as obesity, diabetes, hypertension, and lung disease may face an even higher risk of severe illness, necessitating closer monitoring and aggressive management.
The risk of moderate-to-severe or critical illness during pregnancy appears to increase with increasing maternal age, highlighting the intersection of age-related risks with COVID-19 (Metz 2021, Galang 2021).
Black and Hispanic individuals who are pregnant appear to have disproportionate COVID-19 infection and death rates, reflecting broader health disparities and inequities (Ellington MMWR 2020, Moore MMWR 2020, Zambrano MMWR 2020).
Obstetrician-gynecologists have a responsibility to counsel pregnant individuals and those contemplating pregnancy about the potential risks associated with COVID-19, emphasizing measures to prevent infection with SARS-CoV-2 for these individuals and their families, including vaccination and boosters.
Effect of COVID-19 on Fetal and Neonatal Outcomes
Pregnant people with COVID-19 are at increased risk for adverse outcomes such as preterm birth, preeclampsia, coagulopathy, and stillbirth, compared with pregnant people without COVID-19, underscoring the far-reaching impact of the virus (Allotey 2020, Jering 2021, Ko 2021, Villar 2021, DeSisto 2021).
Neonates born to people with COVID-19 also face increased risks, including admission to the neonatal intensive care unit (Allotey 2020, Villar 2021).
Vertical transmission of SARS-CoV-2, while uncommon, remains a concern, warranting careful monitoring and preventive measures (Dumitriu 2020).
Population level changes in preterm birth and stillbirth rates have been observed during the pandemic, reflecting the broad societal impact of COVID-19.
In Europe, some studies have reported decreases in rates of preterm delivery alongside increased numbers of stillbirths, while initial evidence in the United States suggested preterm delivery and stillbirth rates were largely unchanged (Handley 2020, Hedermann 2020, Kahlil 2020, Yang 2022 ).
Mask Recommendations for Pregnant Patients
Pregnant patients should strictly adhere to the same mask recommendations as the general population, as outlined by the CDC, to minimize the risk of infection and transmission.
Pregnant individuals are at increased risk for severe disease; therefore, it is critically important that pregnant individuals in high COVID-19 hospital admission level areas consistently and correctly use masks in public settings.
There are currently no known risks associated with mask use during pregnancy, reassuring patients about their safety and efficacy in preventing respiratory infections.
CDC recommendations regarding mask wearing may change frequently based on evolving data and public health conditions, and CDC and/or state officials may reinstate mask mandates as needed, requiring flexibility and adaptability.
Routine Screening Testing in Labor and Delivery Units
Pregnant individuals admitted for labor and delivery with suspected COVID-19 or who develop symptoms suggestive of COVID-19 during admission should undergo prompt SARS-CoV-2 testing to guide infection control measures and clinical management (CDC, AMA statement).
Performance of universal SARS-CoV-2 viral testing upon admission to labor and delivery is at the discretion of the facility, considering local prevalence rates and resources.
For asymptomatic patients, the incremental yield of screening testing for identifying infection is likely lower when performed on those in counties with lower levels of SARS-CoV-2 community transmission, impacting cost-effectiveness.
Regardless of vaccination status, individuals may decline testing for various reasons, including stigma, mistrust, and fear of possible mother–baby separation, requiring respectful and sensitive communication.
Facilities that continue to practice routine screening testing in labor and delivery should have a well-defined plan for the care of individuals who decline COVID-19 testing, ensuring equitable access to care and appropriate infection control.
Thromboprophylaxis Management for Pregnant and Postpartum Patients
Pregnancy is inherently a hypercoagulable state, and women who are pregnant or in the postpartum period have a fourfold to fivefold increased risk of thromboembolism compared with nonpregnant women, necessitating careful risk assessment and preventive strategies (Practice Bulletin 196, Thromboembolism in Pregnancy).
Concurrent COVID-19 infection may further exacerbate coagulopathy, increasing the risk of thrombotic events.
The combination of pregnancy and COVID-19 infection may have additive effects on the risk of thrombosis, requiring heightened vigilance and individualized management.
The National Institutes of Health COVID-19 Treatment Guidelines explicitly recommend that pregnant patients hospitalized for severe COVID-19 receive prophylactic dose anticoagulation unless specifically contraindicated, balancing the benefits and risks of anticoagulation.
Antenatal Fetal Surveillance
During acute maternal illness caused by COVID-19, fetal management should be approached similarly to that provided to any critically ill pregnant person, prioritizing maternal stabilization and optimizing fetal well-being.
Continuous fetal monitoring in the setting of severe maternal illness should be considered only after fetal viability, when delivery would not compromise maternal health or serve as another noninvasive measure of maternal status.
Very little is definitively known about the natural history of pregnancy after a patient fully recovers from COVID-19, necessitating individualized management and close follow-up.
In the setting of a mild maternal infection, management similar to that for a patient recovering from influenza is generally reasonable, with attention to symptom monitoring and potential complications.
Patients can experience rapid clinical decompensation after several days of apparently mild illness and thus should be instructed to promptly call or be seen for care if symptoms, particularly shortness of breath, unexpectedly worsen.
A detailed mid-trimester anatomy ultrasound examination may be considered following pre-pregnancy or first-trimester maternal infection to assess fetal development and identify any potential anomalies.
Interval growth assessments could be considered depending on the timing and severity of maternal infection, with the timing and frequency informed by other maternal risk factors, optimizing fetal growth and well-being.
Antenatal testing is typically reserved for routine obstetrical indications, guided by established guidelines and individual patient circumstances (SMFM Coronavirus COVID-19 and Pregnancy).
Infant Feeding with Breastmilk
Breastmilk offers unparalleled protection against numerous illnesses, and there exist few absolute contraindications to breastfeeding, underscoring its immense benefits for infant health.
Current scientific evidence strongly suggests that breastmilk is not a source of COVID-19 infection, alleviating concerns about viral transmission through breastfeeding (Walker 2020, CDC).
Maternal COVID-19, in and of itself, is not considered a contraindication to infant feeding with breastmilk, reinforcing the safety and importance of breastfeeding.
Individuals with suspected or confirmed COVID-19 can potentially transmit the virus through respiratory droplets while in close contact with the infant, including during breastfeeding, necessitating careful preventive measures.
Therefore, patients who intend to infant feed with breastmilk should receive comprehensive counseling on how to minimize the risk of transmission, including:
Breastmilk expression with a manual or electric breast pump, emphasizing proper hand hygiene and thorough pump cleaning after each use.
Enlisting the help of someone who does not have suspected or confirmed COVID-19 infection to feed the expressed breastmilk to the infant, further reducing the risk of transmission.
Implementing stringent safety measures if breastfeeding directly, including meticulous hand hygiene and consistently wearing a well-fitted mask to contain respiratory droplets.
Obstetrician–gynecologists play a crucial role in supporting each patient's fully informed decision about whether to initiate or continue breastfeeding, respecting their autonomy and individual circumstances.
A child being breastfed by someone with suspected or confirmed COVID-19 should be considered as a close contact of a person with COVID-19 and should adhere to quarantine guidelines (CDC).
Mother-Infant Dyad Separation
Early and close contact between the mother and neonate yields well-established benefits, including enhanced success with breastfeeding, strengthened mother-infant bonding, and promotion of family-centered care, all of which contribute to optimal outcomes.
Mother-infant dyads where the mother has suspected or confirmed SARS-CoV-2 infection should ideally room-in according to usual facility policy, preserving the numerous advantages of close proximity.
Current evidence indicates there is no significant difference in the risk of SARS-CoV-2 infection to the neonate whether they are cared for in a separate room or remain in the mother’s room, supporting the practice of rooming-in.
Special Considerations for Incarcerated Pregnant People
Prisons, jails, and detention facilities constitute high-risk environments for COVID-19 transmission due to factors such as crowding and limited access to preventive measures.
For pregnant people who must remain in custody, prisons, jails, and detention facilities should prioritize implementing measures for social distancing, ensuring stringent hygiene protocols, conducting thorough screening and testing, providing comprehensive medical care including COVID-19 vaccination, arranging safe housing, and implementing other interventions as explicitly outlined by the CDC’s Interim Guidance on Management of COVID-19 in Correctional and Detention Facilities and as recommended by guidance from the National Commission on Correctional Health Care.
Institutions of incarceration bear the responsibility of ensuring that pregnant people continue to have uninterrupted access to comprehensive health care, encompassing prenatal care, abortion care, postpartum care and support