Perinatal-Neonatal Management of COVID-19- Updated IAP Guidelines

During second wave of COVID-19 case positivity rate was more than 20% and pregnant women was observed to experience serious illness. The initial guidelines on diagnosis and management of perinatal SARS-CoV-2 infection in India were published in April 2020 and updated in May 2020. The lastest guidelines were updated by IAP based on GDG(Guideline Development Group) recommendations.

Recommendations for the Management of COVID- 19 in Pregnancy and Labor

Pregnant women with COVID-19 have a two-fold higher risk of needing intensive care, mechanical ventilation, extracorporeal membrane oxygenation, and higher mortality. The updated recommendations for management include:

1.Whom to test

- Surveillance in containment zones: test all pregnant women by Rapid Antigen Test(RAT), if it is not available either by RTPCR or TrueNat.

- Surveillance in non-containment zones: test all symptomatic patients, contacts of laboratory confirmed case and history of travel to high risk area either by RTPCR or TrueNat.

-All pregnant women in or near labor and hospitalized for delivery need to be tested by RTPCR or TrueNat.

2. The decision to manage a COVID-19 positive pregnant woman at home or in a health facility depends on obstetric risk factors, comorbidities, the severity of COVID-19 illness, and social conditions.

3. All suspected or confirmed COVID-19 pregnant women should deliver at DCHC (Dedicated COVID Health Centers) or DCH ) Dedicated COVID Hospitals )as per disease severity and availability of obstetric and neonatal services.

4. Dexamethasone given for ten days or until discharge to hospitalized patients with moderate to severe COVID-19 on oxygen or respiratory support has been shown to reduce mortality by 30%.

5. COVID-19 itself is not an indication to terminate a pregnancy or perform a caesarean section. However, a caesarean section may be indicated to manage respiratory failure in critically ill pregnant women with refractory hypoxemia. In asymptomatic/mild disease, pregnancy should be continued until term.

6. Symptomatic pregnant women with persistent fever , moderate or severe COVID-19 illness, or comorbid conditions (poorly controlled hypertension or diabetes, preeclampsia, pre-labor rupture of membranes, bleeding per vaginum) should be admitted to a DCH having an intensive care unit with multidisciplinary support.

7. COVID-19 vaccines can be offered at any gestational age in pregnancy, but the second dose should preferably be completed before the third trimester.

Recommendations for management of neonates with COVID-19

1.Neonatal resuscitation should follow standard guidelines, and providers should use appropriate personal protective equipment (PPE). Delayed cord clamping and skin-to-skin care at birth should be practiced for all stable neonates born to COVID-19 positive women. The risk of postnatal COVID-19 transmission can be reduced if mothers wear a triple layer mask and strictly adhere to respiratory etiquettes.

2. Mother-infant dyads should room-in, and exclusive breastfeeding should be encouraged regardless of maternal COVID-19 status.Expressed breast milk to be given if rooming-in is not possible.

3. Kangaroo care is recommended for low birthweight neonates regardless of the COVID-19 status of the mother or neonate.

4. Symptomatic neonates with suspected COVID-19 should be isolated in a COVID designated area. The suspect and confirmed COVID-19 cases should be segregated.

5. All forms of respiratory support are at risk of generating aerosols, and healthcare providers must wear appropriate PPE.

6.When to test- Neonates born to covid positive mother should be tested at 24-48 hours of age. Asymptomatic high risk contacts to be tested between day 5 and day 10 of contact.

7. Neonates with asymptomatic or mild COVID-19 require no additional routine laboratory tests. Those with moderate or severe COVID-19 illness should undergo relevant biochemical, hematologic, and coagulation tests to assess the complications and rule out alternate diagnoses. Neonates with severe COVID-19 requiring mechanical ventilation, may benefit from dexamethasone, 0.15 mg/kg once daily for 5-14 days. Specific anti-COVID-19 treatment (remdesivir, lopinavir/ritonavir, chloroquine/ hydroxychloroquine, ivermectin, or interferon) and adjuvant therapies (intravenous gamma globulin) are not recommended.

8. Stable mother-infant dyads may be discharged from the health facility after 24-48 hours of delivery if discharge criteria are met, and birth vaccination is completed. All COVID exposed neonates should be followed up for at least 14 days and preferably till 28 days of life.

9. The GDG recommends using the WHO case definition for MIS in children for the neonatal age. Treatment options include intravenous immunoglobulin, methylprednisolone, and aspirin.

Source: IAP pediatrics