Management of pregnancy in pandemic covid-19 - Comment
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Information covered in the presentation slides: 1. MANAGING PREGNANCY IN COVID-19 DR ALKA MUKHERJEE MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY) Dr Alka Mukherjee Nagpur 1 2. INTRODUCTION Global war , Mankind is facing the same enemy - THE NOVEL CORONAVIRUS. PANDEMIC, NATIONAL EMERGENCY Balltlefield - hospitals ; Soldiers - medical workers. Novel coronavirus (sars-cov-2) - new strain - covid-19 Origin - in Wuhan city, China. Main characteristic - person to person transmission - documented in december 2019 Other coronavirus infections Dr Alka Mukherjee Nagpur 2 3. SPREAD & TRANSMISSION Droplet and through Fomites A study showed that stool samples continued to show presence of viral particles for a mean of 29 days after the first symptoms. This is longer than that of samples from the respiratory tract. Need for hygiene and safe sanitation in general. Dr Alka Mukherjee Nagpur 3 4. NON-PHARMACEUTICAL INFECTION PREVENTION AND CONTROL INTERVENTION The greatest tool to prevent COVID-19 - general population and for pregnant women is Social Distancing. As per GOI advisory - implemented to avoid/decrease contact between those who are infected with a disease/pathogen and those who are not, so as to stop or slow down the rate and extent of disease transmission in a community The advisory essentially focuses on measures to be taken by local administration in relation to closure of establishments such as schools, universities, gyms, cultural centers, etc. Dr Alka Mukherjee Nagpur 4 5. Some important aspects for the pregnant woman in India from this advisory are: DISINFECTION OF SURFACES - to reduce fomites related spread. WORK FROM HOME - For women working outside the house, it is preferable to take Work from Home. SOCIAL DISTANCING - Keeping a distance of at least one metre in various necessary interactions and activities AVOID NON- ESSENTIAL TRAVEL. If travel is undertaken, it is preferable to use a private vehicle. If public transport is used, distance should be maintained. AVOID GATHERINGS AND FUNCTIONS to celebrate the 7-month milestone, which is a common cultural practice. MINIMIZE VISITORS from coming to meet the mother and newborn after delivery. Dr Alka Mukherjee Nagpur 5 6. FOR THE ASYMPTOMATIC AND UNINFECTED WOMAN - RECOMMENDED STRATEGY FOR ANTENATAL CARE IS To defer routine visits. Consult the healthcare provider telephonically or through a web platform for minor ailments and questions. Essential milestone visits such as the 12 and 19 week scans are needed. Women are advised to note fetal movements everyday. Dr Alka Mukherjee Nagpur 6 7. Do the ‘FIVE’ - 1.HOME Stay at home as much as possible unless there is a medical need related to development of symptoms of infection or related to pregnancy. Routine antenatal visits are to be deferred. If there is a minor query, it can be sorted out telephonically. Minimize visitors, maids Dr Alka Mukherjee Nagpur 7 8. Washing their hands frequently and properly with a soap and water or an alcohol based hand rub for minimum 20 seconds 2. HANDS Covering their mouth and nose with their bent elbow, handkerchief or tissue while coughing or sneezing. Then the used tissue should be disposed immediately. This is an important component of respiratory hygiene. 3. ELBOW Dr Alka Mukherjee Nagpur 8 9. 4. FACE Avoid touching face, eyes, nose and mouth with hands. Keep a distance of at least 1 meter from the next person outside and in the house. 5. SPACE Dr Alka Mukherjee Nagpur 9 FFP3 masks or N95 (FFP2) masks should be worn by pregnant patients MASKS 10. Precautions for healthcare workers Why are precautions necessary for healthcare workers? Healthcare workers are at high risk of acquiring the COVID-19 infection - because of the contact with large numbers of patients, close contact and procedures where there is spray/aerosolization (resuscitation, ventilation) or splash of body fluids (labour, delivery, surgical procedures) Take universal precautions and use appropriate precautions There is a risk of spread of infection from an infected patient to the healthcare provider and then onward spread to more patients and the population at large. The three principles that healthcare workers should follow Social distancing, Use of appropriate PPE correctly Chemoproph ylaxis. Dr Alka Mukherjee Nagpur 10 11. The healthcare worker should also consider social distancing as the cornerstone of prevention Maintain a distance of at least 1 meter from patients and other healthcare workers. This is possible in clinic settings. However, this may not be feasible during examination, inpatient care and procedures. Remove non- essential items from the consulting or examination room to facilitate cleaning and disinfection and reduce the risk of fomites related spread. Regular hand cleaning with soap and water or alcohol based rubs for at least 20 seconds. Patients should be offered surgical masks if they have respiratory symptoms. Dr Alka Mukherjee Nagpur 11 12. “standard precautions” to cover the risk of transmission through all body fluids. In labour or is undergoing a surgical procedure - enhanced measures using personal protective equipment (PPE) to prevent acquiring infection through respiratory droplets. & masks such as the N95 respirator (ideally fitted to size) and face protection by a face shield or at least goggles and other measures. In the event that appropriate gear for PPE is not available at a particular unit, consider transferring the patient to a centre which is better equipped. If it is an emergency situation and there is limited PPE, it should be allocated to the workers who are caring for pregnant women who are confirmed cases or those who present with symptoms suggestive of acute respiratory illness or those who are close contacts of confirmed cases. Dr Alka Mukherjee Nagpur 12 13. Protocol for Donning PPE FOGSI Good Clinical Practice Recommendation. Version 1 Protocol for removing PPE Dr Alka Mukherjee Nagpur 13 14. Level 3 protection • Disposable surgical cap Medical protective mask (N95) Work uniform Disposable medical protective uniform Disposable latex gloves Full face respiratory protective devices or powered air-purifying respirator • Intubation, resuscitation of suspected/con rmed patients where there is a risk of spray or splash of respiratory secretions of body fluids or blood · Surgery, procedures, delivery of suspected/confirmed patients · Autopsy of suspected/confirmed patients Level 1 protection • Protective Equipment - Disposable surgical cap Disposable surgical mask Work uniform Disposable latex gloves and/or disposable isolation clothing · • Scope of Application Pre examination triage, general outpatient department • Disposable surgical cap Medical protective mask (N95) Work uniform Disposable medical protective uniform Disposable latex gloves Goggles • Fever outpatient department · • Non-respiratory specimen examination of suspected/con rmed patients • · Imaging examination of suspected/con rmed patients • · Cleaning of surgical instruments used with suspected/confirmed patients Level 2 protection Personal Protective Equipment in relation to COVID-19 infection management Dr Alka Mukherjee Nagpur 14 15. ICMR also recommends the use of hydroxychloroquine as prophylaxis for asymptomatic healthcare workers caring for suspected or confirmed COVID-19 infected patients The recommended regimen is to take the tablet of 400 mg hydroxychloroquine twice a day on day 1 and then once weekly for 7 weeks. The medicine should be taken with meals. It is contraindicated in case of known sensitivity to the drug or if a healthcare worker suffers from G6PD deficiency or retinopathy. Dr Alka Mukherjee Nagpur 15 PROPHYLAXIS 16. EFFECT OF COVID-19 ON PREGNANCY Pregnant women do not appear more likely to contract the infection than the general population. However, pregnancy itself alters the body’s immune system and response to viral infections in general, which can occasionally be related to more severe symptoms and this will be the same for COVID-19. Reported cases of COVID-19 pneumonia in pregnancy are milder and with good recovery. In SARS, MERS - the risks to the mother appear to increase in particular during the last trimester of pregnancy. There are case reports of preterm birth in women with COVID-19 but it is unclear whether the preterm birth was always iatrogenic/ spontaneous. Pregnant women with heart disease - at highest risk (congenital or acquired). The coronavirus epidemic increases the risk of perinatal anxiety and depression, as well as domestic violence. It is critically important that support for women and families is strengthened. Dr Alka Mukherjee Nagpur 16 17. Clinical Presentation of COVID-19 in Pregnancy FOGSI Good Clinical Practice Recommendation. Version 1 The mean incubation period (from exposure to the appearance of clinical features) is 5 to 7 days. Most people who are infected will show features latest by 11 days of exposure. A history of travel abroad or contact with someone who has travelled abroad should be included in the history taking. The majority of people (pregnant and general population) present with respiratory symptoms of COVID-19 infection. Dr Alka Mukherjee Nagpur 17 Given that pregnancy is known to be a hypercoagulable state, and emerging evidence suggests that individuals admitted to hospital with COVID-19 are also hypercoagulable, it follows that infection with COVID-19 is likely to be associated with an increased risk of maternal venous thromboembolism (VTE). Reduced mobility resulting from self-isolation at home, or hospital admission, is likely to increase the risk further. The diagnosis of PE should be considered in women with chest pain, worsening hypoxia (particularly if there is a sudden increase in oxygen requirements) or in women whose breathlessness persists or worsens after expected recovery from COVID-19. 18. Clinical Presentation of COVID-19 in Pregnancy FOGSI Good Clinical Practice Recommendation. Version 1 - Most pregnant women will have mild to moderate Flu-like symptoms of cough, sore throat, and fever . - Few may have difficulty in breathing or shortness of breath. These have been classifed as features of severe acute respiratory illness (SARI) by the WHO. - Pregnant women, especially those with associated medical diseases (diabetes, asthma, etc) may present with pneumonia and marked hypoxia. - Immuno-compromised and elderly pregnant women may present with atypical features such as fatigue, malaise, body ache and/or gastrointestinal symptoms like nausea and diarrhea Dr Alka Mukherjee Nagpur 18 19. EFFECTS OF COVID-19 INFECTION ON THE FETUS • Preliminary research had suggested that the infection is not transmitted from the mother to child by placental transfer. • However, there is emerging evidence that now suggests that vertical transmission is probable. • Two reports have published evidence of IgM for SARS-COV-2 in neonatal serum at birth. Since IgM does not cross the placenta, this is likely to represent a neonatal immune response to in utero infection. • The proportion of pregnancies affected and the significance to the neonate has not been determined. At present, there seems to be no clinically significant effect on the neonate even when infected. • In other reports including a total of 18 pregnant women with suspected or confirmed COVID-19 pneumonia, all of the newborns, who were delivered via cesarean section, tested negative for the corona virus, and there were no traces of the virus in the mother's amniotic fluid, cord blood or breast milk. • An ultrasound 14 days after the infection can be considered for the pregnant woman who has recovered from infection Dr Alka Mukherjee Nagpur 19 - Maternal disease does not get aggravated by pregnancy unless there are co- morbidities. 20. Testing for COVID-19 in Pregnancy FOGSI Good Clinical Practice Recommendation. Version 1 - As per the guidance given by ICMR pregnant women should be tested in the following circumstances • 1. A pregnant woman who has acute respiratory illness with one of the following criteria: • a 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 home quarantine for 14 days. • is a close contact of a laboratory proven positive patient or • she is a healthcare worker herself or hospitalized with features of severe acute respiratory illness. • 2. A pregnant woman who is presently asymptomatic should be tested between 5 and 14 days of coming into direct and high risk contact of an individual who has been tested positive for the infection. Dr Alka Mukherjee Nagpur 20 21. Testing for COVID-19 in Pregnancy FOGSI Good Clinical Practice Recommendation. Version 1 - Test methods and facilities – presently the RT-PCR test from nasopharyngeal swab is used for diagnosis. - Sputum should only be collected from patients with productive cough - NAAT is a gold standard test - expensive and involves the risk of multiplication of viral particles. - Serological testing is faster and cheaper. At a population level, serological testing may be more feasible to see the prevalence. Also, after 3 weeks of infection, the RT-PCR would be negative, but serology would give the diagnosis Dr Alka Mukherjee Nagpur 21 22. Dr Alka Mukherjee Nagpur 22 23. OTHER INVESTIGATIONS • Leucopenia, Lympho-cytopenia, Mild Thrombocytopenia, Mild Elevation Of Liver Enzymes And Other Acute Infection Markers. • Co-infection with other common respiratory pathogens and the common cold virus are often seen with COVID-19. • CT scan and other imaging modalities usually show patterns consistent with atypical pneumonia. • X-Ray/ CT scan is needed for a pregnant woman, there should be provision of an abdominal shield to protect the fetus from radiation exposure. • An informed consent for the imaging should be taken from the pregnant woman and her relatives. • Guidelines for notifying COVID-19 affected persons by Private Institutions have been given by the Government of India(23). In the wake of the prevailing COVID-19 situation, it is of utmost importance that each and every case (suspects/con rmed) of COVID-19 is isolated and provided appropriate treatment and their contacts are traced at the earliest to break the chain of transmission. NOTIFICATION OF COVID-19 CASES Dr Alka Mukherjee Nagpur 23 24. QUARANTINE FOR PREGNANT WOMEN IN THE TIMES OF COVID-19 PANDEMIC • Quarantine is used to separate and restrict the movement of well persons who are known to be exposed (directly or indirectly) or suspected to be exposed to a communicable disease to see if they become ill. These people may have been exposed to a disease and remain asymptomatic – CAN BE at home or hotels, hostels, guesthouses or hospitals. effective measure against the spread • Isolation refers to the separation and restriction of movements of ill persons who have a contagious disease in order to prevent its transmission to others. It typically occurs in a hospital setting or a special facility. At present, in India, all symptomatic patients who have a positive test for COVID19 are being isolated. • The criteria for quarantine are the same for pregnant women and the general population. Dr Alka Mukherjee Nagpur 24 25. A CONTACT IN THE CONTEXT OF COVID-19 IS: • A person living in the same household as covid • Direct physical contact with covid person or his secretions without PPE/possible breach of PPE • Closed environment/face to face contact less than 1 meter/air travel • GENERAL MEASURES - • include hand washing, avoiding sharing fomites, wearing a surgical mask and changing it every 6 to 8 hours with correct disposal in 1% hypochlorite solution. • If symptoms appear during quarantine, the pregnant woman should contact a health facility by telephone and follow the given advice. • Family members of the pregnant woman quarantined at home should keep a distance from her at all times and avoid direct contact with her and her fomites. • Disposable gloves should be used in case soiled linen has to be handled. • Visitors should not be allowed. • Clothes should be washed separately. • The duration of home quarantine is 14 days from the time of exposure to a confirmed case or earlier if a test is performed on a suspect case and it is negative. Dr Alka Mukherjee Nagpur 25 26. Instructions for contacts, being home quarantined • Stay in a well-ventilated single-room preferably with a attached/separate toilet • If another family member needs to stay in the same room, it's advisable to maintain a distance of at least 1 meter between the two. • Needs to stay away from elderly people, pregnant women, children and persons with co-morbidities within the household • Restrict his/her movement within the house. • Under no circumstances attend any social/religious gathering e.g. wedding, condolences, etc. Dr Alka Mukherjee Nagpur 26 27. Arrangements in existing healthcare facilities to manage COVID-19 exposed and infected pregnant women FOGSI Good Clinical Practice Recommendation. Version 1 - Every pregnant woman should be triaged at entry and then allotted into one of the zones depending on the presentation. - The infected and potentially infected pregnant women should be kept in separate isolation areas. Each isolation area includes isolation wards, and an isolation ICU area. If possible, each patient should be kept in a separate room with an attached bathroom. Dr Alka Mukherjee Nagpur 27 28. Assessment of Pregnant women (not in labour) with COVID-19 infection • As of date (25 Mar 2020), all confirmed cases are being hospitalized in India for isolation and observation to watch for progress of symptoms • In the future, if there is a need to restrict hospitalization due to limited bed availability, pregnant women should be hospitalized if they have clinical or imaging features of pneumonia or systemic disease • A quick bedside assessment tool is also usable for sepsis (typically for bacterial infections) screening in triage called the quick SOFA (qSOFA) score. It includes 1 point for each of 3 criteria. •Pregnant women who meet any of the following criteria: •· respiratory rate > 30 breaths/min; •· oxygen saturation < 93% at a rest; •· arterial partial pressure of oxygen •(PaO2)/oxygen concentration (FiO2) < 300 mm Hg • · Patients with > 50% lesions progression within 24 to 48 hours in lung imaging • · Quick Sequential Organ Failure Assessment Score (qSOFA) score can be a useful adjunct to decision making for ICU management. Dr Alka Mukherjee Nagpur 28 qSOFA SCORE Score ≥ 2 is suggestive of sepsis and needs intensive care Number Criteria Point 1. Respiratory rate ≥ 22 breaths/min 2. Mental status Altered 3. Systolic Blood pressure ≤ 100 mm Hg 29. Flowchart FOGSI Good Clinical Practice Recommendation. Version 1 Dr Alka Mukherjee Nagpur 29 30. Medical management and drugs used in the treatment of COVID-19 infection in pregnancy FOGSI Good Clinical Practice Recommendation. Version 1 Supportive therapy: rest, oxygen supplementation, uid management and nutritional care as needed. - Hydroxychloroquine 600 mg (200 mg TDS with meals) and Azithromycin (500 mg OD) for 10 days has been used successfully. - Antiviral therapy (Lopinavir + Ritonavir or Oseltamavir) may be used in high risk groups (Immunocompromised, Chronic disease, Uncontrolled diabetes). - Some health authorities have prescribed a regimen of Oseltamavir 75 mg twice a day for ve days in conjunction with hydroxychloroquine - NSAIDs: These are the drugs used most often in the care of COVID-19 infected pregnant women for symptomatic relief of fever and myalgia. Paracetamol is the preferred drug. If possible, Ibuprofen and other NSAIDs may be avoided because there are concerns about potentiating ACE receptors. Dr Alka Mukherjee Nagpur 30 31. ANTIVIRAL THERAPY • Lopinavir-ritonavir was the first antiviral combination used in an attempt to treat COVID-19 infection. • This may be considered as a possible line of treatment for those who have chronic disease, immunocompromised or uncontrolled diabetes. • However, there was no difference in time to clinical improvement or mortality at 28 days in a randomized trial of 199 patients with severe COVID-19 given lopinavir-ritonavir (400/100 mg) twice daily for 14 days in addition to standard care versus those who received standard care alone • Other agents such as Remdesivir(59), Favipriavir (61) are being evaluated in a randomized trials. • In India, some health authorities have prescribed a regimen of Oseltamavir 75 mg twice a day for ve days in conjunction with hydroxychloroquine. The recommendation is based on the experience of the H1N1 (swine flu) experience. At present, data on this regimen is limited. The regimen is simple, cost effective and the drug is available easily. Dr Alka Mukherjee Nagpur 31 32. Other Drugs FOGSI Good Clinical Practice Recommendation. Version 1 - Antenatal Steroids (foetal maturity): Steroids are recommended for enhancing foetal lung maturity in situations where preterm delivery is likely between 24 to 34 weeks of gestation. There is no documented evidence of the use of steroids in COVID-19 infection. Therefore, the use of steroids needs to be individualized based on the woman's condition and should be discussed with her and her family. - Antihypertensive: there is controversy surrounding the use of ACE inhibitors and arbs in the general population, especially the elderly with hyper tension. In pregnancy, these drugs are not to be used due to their known deleterious effects on the foetus. The point of using them in pregnant women, therefore, does not arise. - Antibiotics: If there is a suspicion of secondary bacterial infection, appropriate antibiotics which are considered safe in pregnancy should be added. Dr Alka Mukherjee Nagpur 32 33. FOGSI Good Clinical Practice Recommendation. Version 1 DIET - There are no special diets. Rumors related to diet should be dispelled - There is no particular diet that is recommended to treat or use as part of the treatment against COVID-19 infection in a pregnant woman or in the general population. - There is also no evidence that consumption of meat, chicken or eggs leads to a higher risk of acquiring COVID-19 infection. - Based on such limited evidence, dietary advice is generic and would include a high protein diet and vitamin and micronutrient supplementation. Dr Alka Mukherjee Nagpur 33 34. Management of Labour and Delivery in women with COVID-19 infection - Separate delivery room and operation theatres are required for management of suspected or confirmed COVID-19 mothers. - Both should have neonatal resuscitation corners located at least 2 m away from the delivery table. - Resources required include space, equipment, supplies and trained healthcare providers for delivery, caesarean section and neonatal resuscitation. https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetricsDr Alka Mukherjee Nagpur 34 - If a woman presents in preterm labour, tocolysis is contraindicated - If there is pulmonary involvement, beta-mimetic agents should be avoided. - Timing of delivery should not be altered on the basis of COVID-19 infection. The presence of infection is not an indication to induce labour or deliver the woman. - At present, there is no evidence of trans-placental vertical transmission. There would be no rationale in doing so. 35. Flowchart FOGSI Good Clinical Practice Recommendation. Version 1 Dr Alka Mukherjee Nagpur 35 36. IS OPERATIVE VAGINAL DELIVERY INDICATED IN A PATIENT WITH SUSPECTED OR CONFIRMED COVID-19? - No, operative vaginal delivery is not indicated for suspected or confirmed COVID-19 alone. - Practitioners should follow usual clinical indications for operative vaginal delivery, in the setting of appropriate personal protective equipment https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetricsDr Alka Mukherjee Nagpur 36 - Yes, delayed cord clamping is still appropriate in the setting of appropriate clinician personal protective equipment. - Current evidence-based guidelines for delayed cord clamping should continue to be followed until emerging evidence suggests a change in practice. Is delayed cord clamping still appropriate in a patient who has suspected or confirmed COVID-19? 37. How should umbilical cord blood banking be managed during the COVID-19 pandemic? - Currently, there are no reported cases of transmission of COVID-19 by blood products; therefore, umbilical cord blood banking can continue to be managed according to clinical guidance, in the setting of appropriate clinician personal protective equipment. https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetricsDr Alka Mukherjee Nagpur 37 Should expedited discharge be considered during the COVID-19 pandemic? - Yes. To limit the risk of inadvertent exposure and infection, it may be appropriate to expedite discharge when both the mother and the infant are healthy - For example, discharge may be considered after 1 day for women with uncomplicated vaginal births and after 2 days for women with cesarean births depending on their status. - Early discharge will require discussion with the facility’s pediatric care team and should be linked to home telehealth visits for the mother and infant. 38. BREASTFEEDING - The CDC states that “we do not know whether mothers with COVID-19 can transmit the virus via breast milk” - The main risk for infants of breastfeeding is the close contact with the mother , who is also likely to share infective airborne droplets – explain her universal precautions, hand wash & use of mask. - 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 . - If the woman is isolated from the neonate, she should be offered psychological assessment and support. These interventions can be safely provided by teleconsultation FOGSI Good Clinical Practice Recommendation. Version 1 Dr Alka Mukherjee Nagpur 38 39. Are there additional components to postpartum care that should be considered? - Offer modified postpartum counselling regarding: Any potential changes to the length of hospital stay and postpartum care Any special considerations for infant feeding Postpartum contraception https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetricsDr Alka Mukherjee Nagpur 39 - Abortion care is essential healthcare. - It is critical to ensure that women who seek abortion and family planning do not suffer from lack of access. - A lack of these services may mean that women seek an abortion from unsafe providers and put themselves in harm's way. The services should therefore continue to be provided by public and private providers. TERMINATION OF PREGNANCY (MTP) 40. COVID-19 CONSENT FORM • I/we have been explained in detail about prevailing pandemic condition of COVID-19. I/We had also been explained about possibility of transmission of infection from me/my relative/s who has/have accompanied me/us to doctor, hospital staff, other patients, their relatives and other visitors of hospital and vice-versa from doctor, hospital staff, other patients, their relatives, other visitor of hospital to me and my relative/s who has accompanied me. I/We also had been explained about incubation period of the infection and its importance. If I have been asymptomatic carrier or an undiagnosed patient with COVID-19 and if I/we turn positive for COVID-19 infection afterwards or even after discharge from the hospital, I/we give assurance to inform doctor and hospital immediately, failing which may invite serious consequences including legal proceedings against me/us I/we declare that we neither have concealed nor represented in false or fabricated manner any information I/we was/were asked to provide by doctor and /or hospital staff. I/We had been explained everything in detail about COVID-19 infection in language we could understand. I/We have been explained possibility of any further test, involvement of other doctors, change in treatment protocol/ transfer to other hospital/designated center for COVID-19 infection treatment any time during course of treatment • After understanding in detail the above I/we give our free and fair consent in sound state of mind without any pressure, threat, coercion or under in uence of any intoxication for admission/treatment/procedure/surgery/operation to Dr……………………………………………………………………………………..............................................;.. • Signature of doctor Name Registration No. Age Address • Signature/thumb impression of patient Name Age Address Date • Signature of witness Name Age Address Date Date Signature of witness Name Age Address Date Dr Alka Mukherjee Nagpur 40 41. Measures for Pregnant Women to Prevent COVID-19 infection Social Distancing – could be the single most important intervention at population level Do the Five – Staying at home, Hand hygiene, Respiratory hygiene, Avoiding touching the face and Keeping distance should be practiced. Wearing a mask is recommended. Precautions for healthcare workers (HCW) HCW are at high risk of getting infected. Precautions are necessary to protect themselves and prevent spread to others. Distancing – where possible, HCW should keep a distance and practice hand hygiene Personal Protective Equipment (PPE) – use should be according to clinical situation. Covering of all surfaces especially hands and face is vital. Proper technique to wear and remove PPE is essential. Chemoprophylaxis – is recommended with Hydroxychloroquine only for HCW with known contact of COVID-19 positive patients. In case of accidental exposure, complete protocol should be followed. Clinical Presentation and maternal effects of COVID-19 in Pregnancy A history of travel abroad, contact and respiratory symptoms should be elicited at every clinical interaction. Most pregnant women will present with mild symptoms and have a similar course to other adults with COVID-19 infection. Maternal diseases may get agravated if associated with co-morbitites. COVID-19 infection could exaggerate the hypercoagulable state. Mental health issues and domestic violence should be considered in assessing the woman.Dr Alka Mukherjee Nagpur 41 42. Effects of COVID-19 infection on the fetus There is emerging evidence from immunological assessment that in-utero transplacental infection to the fetus may occur. The virus has not been isolated in amniotic uid or vaginal secretions. The neonatal effects seem to be minimal. Testing for COVID-19 in Pregnancy COVID and non-COVID facilities need to be de ned. There has to be comprehensive maternity services available at COVID hospitals. COVID positive mothers should be delivered in a separate and dedicated Labour Room and Operation Theatre. In case of an emergency where these facilities are not available, the LR and OT should be properly fumigated. Non-COVID hospitals need to make changes such as triage, checklist and referral pathways to minimize accidental infection transmission risk. COVID Checklist Tool A checklist should be used to identify suspect patients. They should be referred for testing. This may not be a foolproof method but in the absence of rapid testing, it is a useful approach. Termination of pregnancy (MTP), sexual and reproductive healthcare services are time sensitive and their provision is essential during the pandemic for all women. Antenatal Care Visits should be optimized and timed. PPE, distancing and hygiene precautions are necessary. Clinic organization is important to reduce transmission risk. Clinic fomites should be disinfected. At the end of the day, the room should be disinfected or fumigated. Telemedicine should be used as appropriate. Dr Alka Mukherjee Nagpur 42 43. Obstetric Ultrasound Due to prolonged examination time, small room size and proximity, transmission risk is high with obstetric ultrasound. Minimum number of probes should be used. In a hospitalized woman, bedside ultrasound is preferable. Ultrasound machine and fomites should be disinfected. The probe should be washed, dried and disinfected. At the end of the day, the room should be disinfected or fumigated Assessment of Pregnant women (not in labour) Recognizing the critically ill woman – Most women will not need hospitalization or critical care. Tachypnoea (> 30/min), hypoxia (SpO2 < or = 93%) and imaging showing > 50% lung involvement indicate a need for critical care. Medical management and drugs used in the treatment of COVID-19 infection in pregnancy Hydroxychloroquine 600 mg (200 mg thrice a day with meals) and Azithromycin (500 mg once a day) for 10 days has been used successfully. Antiviral therapy (Lopinavir + Ritonavir or Oseltamavir) may be used in high risk groups (immunocompromised, chronic disease, uncontrolled diabetes). Other supportive care should include rest, supplemental oxygen and paracetamol. Plasma therapy is being assessed in trials. Management of Labour and Delivery in women with COVID-19 infection There is no rationale to induce labour or deliver a woman early because of COVID-19 infection. Decisions regarding route of delivery should be as per standard obstetric practice or as per the maternal condition. Dr Alka Mukherjee Nagpur 43 44. • Management of Labour and Delivery in women with COVID-19 infection • There is no rationale to induce labour or deliver a woman early because of COVID-19 infection. Decisions regarding route of delivery should be as per standard obstetric practice or as per the maternal condition. • Labour Analgesia and Anesthesia in Pregnant Women with COVID-19 infection Regional analgesia and anesthesia can be used in women with COVID-19 infection. Specialized techniques can be adopted for general anesthesia. • Newborn care should be practiced as per routine. At present, testing is recommended if the mother has COVID-19 infection or if the baby is symptomatic. Breastfeeding is encouraged with good hygiene practices. • Cleaning, maintenance of facilities and medical equipment should be done with adequate PPE to the HCW. 1% sodium hypochlorite solution with contact time of 30 minutes can be used. • Postnatal Care and Advice to the mother infected with COVID-19 should follow routine practice. If the woman is isolated from the neonate, she should be offered psychological assessment and support. • Diet for the pregnant woman and COVID-19 infection should be as per routine. There are no special diets. Rumors related to diet should be dispelled. A nutritious diet helps to build immunity. • Training and managing the healthcare cadre is essential to prevent them from getting infected. Training should include donning and dof ng. Duty allocation and duration of shifts should be regulated. It is important to keep up morale Dr Alka Mukherjee Nagpur 44 45. PLASMA THERAPY • One of the experimental approaches been attempted for critically ill patients is the infusion of plasma from individuals who have recovered from the COVID-19 infection. This approach is based on the passive transfer of antibodies from the recovered person to the critically ill person. The initial reports of the treatment are encouraging. • In India, the ICMR has published a letter of intent calling for participation of institutions in a randomized controlled study on Therapeutic Plasma Exchange in COVID-19 and published a protocol for the same. • The ICMR emphasizes that this is an experimental treatment to be performed only in settings of a clinical trial and not for routine use, even for individuals in critical care with COVID-19 infection. • From • Vaccine - At present, a number of organizations in the public and private sector are working towards the development of a vaccine. Some safety trials have been initiated. However, it is estimated that a vaccine would be available to use only after 6-12 months. Dr Alka Mukherjee Nagpur 45 46. From today 12/06/2020 Dr Alka Mukherjee Nagpur 46 47. Dr Alka Mukherjee Nagpur 47 |
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| Posted by : peter88 | Post date : 2020-06-12 23:08 | ||
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