Dr. Shaheen Anjum, MS (Obstetrics & Gynaecology).
COVID-19 Pandemic: In Vitro Fertilization (IVF) and Pregnancy.
The outbreak of the COVID disease (COVID-19) originated in Wuhan, China in December 2019. The World Health Organization (WHO) declared it a Public Health Emergency of International Concern on January 30, 2020 and then as a pandemic on March 11, 2020.
The etiology of this illness is now attributed to a novel virus belonging to the Corona virus (CoV) family. Initially, the new virus was called 2019-nCoV. Subsequently, the taskforce of experts of an International Committee on Taxonomy of Viruses (ICTV) termed it the SARS-CoV-2 as it is very similar to the one that caused the SARS outbreak (SARS-CoVs). The CoV’s (corona viruses) have now established themselves as major pathogens of emerging respiratory disease outbreaks. They are a large family of single-stranded RNA viruses (+ssRNA) that can be isolated from different animal species.
According to WHO & CDC, pregnant women seem to have the same risk as adults who are not pregnant. However, pregnant women have changes in their bodies that may increase their risk of some infections and also have had a higher risk of severe illness when infected with viruses from the same family as COVID-19 and other viral respiratory infections, such as influenza.
There data available on the clinical presentation of COVID-19 in pregnant women is sparse as of now. There is currently no known difference between the clinical manifestations of COVID-19 in pregnant and non-pregnant women or adults of reproductive age.
Most pregnant women will have mild to moderate flu-like symptoms such as cough, sore throat, and fever. Few may have difficulty in breathing or shortness of breath. These have been classified as features of severe acute respiratory illness (SARI) by the WHO. Pregnant women, especially those with associated medical diseases (diabetes, asthma, heart disease etc) may develop pneumonia and marked hypoxia. Immuno-compromised and elderly pregnant women may develop atypical features such as fatigue, malaise, body ache and/or gastrointestinal symptoms like nausea and diarrhea.
Testing for COVID-19 in Pregnancy:
As per the Indian Council for Medical Research (ICMR) guideline, pregnant women should be tested under the following circumstances:
a. A pregnant woman who has acute respiratory illness along with history of travel abroad in the last 14 days (6 March 2020 onwards). In addition to testing, these individuals (with or without symptoms) and their household contacts should be home-quarantined for 14 days.
b. Patient is in close contact of a laboratory proven positive patient, a healthcare worker herself or hospitalized with features of severe acute respiratory illness.
c. A pregnant woman who is presently asymptomatic should be tested between 5 and 14 days of coming into direct and/or high-risk contact of an individual who has been tested positive for the infection.
According to the Government of India, direct and high-risk contact is defined as any person living in the same household, traveling together by any conveyance, working together in close proximity (same room) or healthcare workers providing direct care.
Mother to Child Transmission:
As COVID-19 is rapidly spreading, maternal management and fetal safety has become a major concern. However, there is scarce information on the assessment and management of pregnant women infected with COVID-19 and the potential risk of vertical transmission is unclear.
Recent updates on pregnancy outcomes in infected mothers report healthy infants born free of the disease. There is no increase risk of abortions and early pregnancy loss, However, there are a small number of case reporting adverse outcomes such as premature rupture of membranes and preterm delivery. Neonatal SARS-CoV-2 infection (five cases) and the presence of IgM (and IgG) antibodies against the virus in newborns (three cases) have also been reported by various studies. It is unclear whether this data is indicative of vertical transmission of SARS-CoV-2.
Antenatal Care For Non-Infected COVID- 19 Pregnant Women:
The main aim is to provide high quality maternity care including mental and psychological counseling. Antenatal visits should be reduced unless it is a high-risk pregnancy. Telephone numbers or online services should be provided so that new mothers can contact healthcare providers in case of any problem such as fever, cough or difficulty breathing or any obstetric complaints. Dietary advice should also be given. They should be advised to follow general hygiene and social distancing measures. This will help reduce the transmission of COVID-19. Some measures are as follows:
a. Avoid close contact with people suffering from acute respiratory infections.
b. Wash your hands frequently, especially after contact with infected people or their environment.
c. Avoid touching your eyes, nose and mouth.
d. Practice respiratory hygiene. This means covering mouth and nose with elbow or tissue during cough or sneeze. Then dispose the used tissue immediately.
e. Avoid unprotected contact with farm or wild animals.
f. Avoid non-essential use of public transport when possible.
g. Work from home, when possible.
h. Avoid gatherings with friends and family. Keep in touch using technology such as phone, internet, and social media.
Antenatal Care For Suspected or Confirmed COVID- 19 Pregnant Women:
Hospitals should have isolation zones which should include Outpatient wards (OPD’s), ICU’s, Labour rooms and operation theaters demarcated for COVID-19 infected women.
All women have the right to a safe and positive childbirth experience whether or not they have a confirmed COVID-19 infection. Medical staff should take all preventive measures to protect themselves as well as cross infection to other patients. Medical staff should be prepared to tackle maternal and neonatal complications.
Most women do not need hospitalization unless in labour, experiencing some obstetric and/or medical problem or critically ill. If there is tachypnoea (>30/min), hypoxia (SpO2 < 93%) and imaging showing > 50% lung involvement, it indicates a need for critical care. Multidisciplinary consultations from obstetric, perinatal, neonatal and intensive care specialists are essential for these patients.
There is no rationale in inducing labour to make a woman deliver early because of COVID-19 infection. Decisions regarding route of delivery should be as per standard obstetric practice in most situations.
COVID-19 and In Vitro Fertilization (IVF):
The ESHRE & the ASRM recommendations regarding infertility patient management are as follows:
a. Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations (IUIs), in vitro fertilization (IVF) including retrievals and frozen embryo transfers, as well as non-urgent gamete cryopreservation.
b. Strongly consider cancellation of all embryo transfers whether fresh or frozen.
c. Suspend elective surgeries and non-urgent diagnostic procedures.
d. Minimize in-person interactions and increase utilization of tele-health.
Please remember, you are your own best advocate. Yes, you have a full right to ask any questions with experts and you have a right to discuss your concern with your visiting doctor.
Dr. Shaheen Anjum, MS (Obstetrics & Gynaecology), M.L.N Medical College, Allahabad, Uttar Pradesh.
Professor & In-charge ART Unit, Department of Obstetrics & Gynaecology , JN Medical College, AMU, Aligarh, Uttar Pradesh, India.
April 14, 2020
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