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COVID-19 Q&A

Below is a summary of the content from our COVID-19 Q&A session with Dr. Elizabeth Cates, RM, PhD on April 7, 2020. We have adapted the slides written by Dr. Cates and incorporated some relevant links. Please note that our understanding of COVID-19 is evolving. Although we will try to stay up to date, the information posted may not reflect the latest news and guidance. Please check with your primary care provider for up to date information.

 

 

Your COVID-19 Questions Answered

  • A large family of viruses
  • Helical, enveloped,
  • SS(+) RNA viruses
  • Named for the corona “crown” that the proteins of their viral envelope make around them
  • Infects birds and several mammalian species (including humans)
  • Tropisim for the lungs/respiratory tract in humans (ie. they are attracted to our lungs)
  • There are 7 corona viruses known to infect humans:
    • 4 of them cause the “common cold”
    • SARS-CoV-1 (SARS)
    • HCov-229E (MERS)
    • SARS-CoV-2 (COVID-19)
  • COVID-19 stands for Corona Virus Diseases (from a novel corona virus discovered in 2019)
    • Caused by the virus SARS-CoV-2 (also called HCoV-19)
  • Reservoir species = bats
    • Hypothesized that Malayan pangolins, illegally imported into China were the intermediary species that facilitated the “jump” to humans
  • Viruses need a very specific “lock & key” system to get into cells
    • Binds to human cells via ACE2 and infects them via that route
    • Certain groups are more affected because they have more of the receptors that the virus uses to get into the cell
      • Men have more of this receptor and are therefore more susceptible 
  • First identified in Wuhan, Hubei province China
  • Evidence suggests that the virus was NOT made/manipulated in a lab
  • The virus spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes
  • The virus enters your body through mucous membranes (eyes, nose, mouth)
  • If you are standing too close to an infected individual and they cough or sneeze on you, you can breath in the droplets and contract the virus
    • This is why physical distancing and respiratory hygiene are so important
  • If you touch a surface coated with infected droplets and then transfer these to your mucous membranes (ie touch your face) you can become infected
    • Wearing gloves does NOT prevent this! In fact, it makes it potentially more likely
  • Remember, viruses don’t DO anything! People spread viruses to people!
  • STAY HOME

To read the WHO Q&A on COVID-19 pregnancy, childbirth and breastfeeding go here: https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-pregnancy-childbirth-and-breastfeeding

  • There is no treatment for COVID-19
  • There is supportive care for some symptoms, but no cure
  • The only way to get better from this virus is for your immune system to fight it off
  • There is currently no vaccine

To read the WHO Q&A on COVID-19 pregnancy, childbirth and breastfeeding go here: https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-pregnancy-childbirth-and-breastfeeding

Public Health Policy/Rules

  • Stay home- do not go out to work (if you’re a non essential worker), school or other public places
  • Avoid public transit
  • Only go out for essentials, shop online and use delivery when possible
  • Avoid common physical greetings such as handshakes and hugs
  • No visitors unless essential (ex. Health care providers [HCPs])
  • Virtual playdates for children. No playgrounds, parks, etc.
  • Gatherings of more than 5 people were banned in Ontario at the end of March
  • Keep a distance of at least 2 m from others at all times
  • Wash your hands with soap and water
    • Use an alcohol-based hand sanitizer if soap and water are unavailable

To read CDC recommendations on how to protect yourself and others go here: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html

Your Questions

 

Questions mainly fell into the following categories:

  1. Protection – self, clinic/hospitals
  2. Risks – mom, baby, pregnancy
  3. Expectations – Prenatal, birth, postpartum

Institutional Precautions

  • All precautions centre around people spreading the virus to people through droplets
  • Enforcing physical distancing
    • No visitors at appointments or in hospital
    • Only essential procedures/visits are in-person (moved to virtual care when possible)
      • This keeps individuals at home
      • Keeps centres less crowded for people who are required to be in them
  • Disinfecting surfaces
  • PPE
    • Different equipment will be worn based on the kinds of procedures being performed and whether the patient is sick or not
    • Availability is key!
    • Different centres will do different things – resist the urge to compare!
      • Different providers may do different things so check with your individual provider

Antenatal care

  • Standard schedule of prenatal appointments in Ontario prior to the pandemic:
    • Once a month until 26 weeks, every other week until 36 weeks, once a week until delivery (approximately 16 visits)
    • This is actually many more visits than recommended by the WHO
  • WHO recommended schedule of prenatal appointments:
    • One visit in the first 12 weeks, 20, 26,30,34,36,38,40 (8 appointments)
  • Many HCPs are transitioning to the WHO schedule for in person appointments (we’re coming DOWN to the global standard)
  • Virtual/phone visits wherever possible
  • Extra in person visits if your HCP feels they’re clinically indicated
  • If you have been booked for an in-person visit you should attend as it has been booked for a reason
    • If your HCP is planning many more visits than the standard you can ask for clarification

Pregnancy

  • While it’s too soon to say for sure, vertical transmission looks unlikely
  • Coronaviruses, in general don’t appear to cross the placenta
  • No evidence of vertical transmission in any cases of SARS, MERS, or COVID-19
  • Limited data currently available from China specific to COVID-19:
    • Study of 9 women with COVID-19 pneumonia (these women were quite ill with COVID-19)
    • Virus could NOT be detected in their amniotic fluid or cord blood at delivery
    • Babies were swabbed at delivery and all tested negative for the virus
    • No virus detectable in breastmilk
  • Larger study from NYC:
    • 43 women who tested positive for COVID-19 (most of these women were mildly ill or asymptomatic (ie no symptoms)
    • None of the babies has tested positive for COVID-19 and are continuing to be followed
  • While it’s too soon to say for sure, we don’t think pregnant people have an increased risk of COVID-19 – cautious optimism
  • In general, due to the physiologic changes that happen in pregnancy, pregnant women experience worse outcomes than non-pregnant women when they acquire lower respiratory tract infections (ie influenza, SARS, MERS)
  • Of the known COVID-19 affected pregnant women studied, outcomes were better than would have been expected for SARS
    • ⅓ of women in the NYC study were asymptomatic
    • Vast majority of symptomatic women had mild-moderate pneumonia
    • Pregnancy outcomes of reported cases have been largely good
    • The women who became extremely ill had pre-existing co-morbidities (ie. other chronic conditions)
  • As with the non-pregnant population, outcomes are likely to be correlated with the degree of pre-existing illness (e.g. high blood pressure, diabetes)
  • Range of illness in the pregnant populations studied has been similar to the general population
  • Miscarriage occurs in 25% of all pregnancies
  • Miscarriage, preterm labour/birth are correlated with any significant infection in pregnancy
  • Stillbirth can occur in any pregnancy (~1%)- in most cases the cause is unknown
  • Data difficult to interpret to date in the case of COVID-19 and pregnancy
    • Preterm birth has been the most common adverse outcome
      • Not because the virus directly, or because it caused preterm labour, but because the women were given C-sections when they were found to have the virus (as long as they were in their 3rd trimester)
      • 1 stillbirth reported in the case of severe maternal illness
  • No evidence to suggest that there is an increased risk of miscarriage or early pregnancy loss in COVID-19 positive people
  • No reported cases of teratogenicity or chromosomal anomaly with any of the coronaviruses to date (ie it doesn’t appear to cause birth defects in babies)
  • Pregnancy outcomes in COVID-19 positive people have been good
  • The risk of transmission during delivery appears to be low
  • Of the babies born to COVID-19 positive women, no virus has been detected in amniotic fluid or cord blood, and all neonates were negative for virus at delivery
  • Potential for fecal-oral transmission
    • Genetic material from the virus has been found in stool samples
      • Is this from intact virus? We don’t know
    • Water birth discouraged at this time
      • This is for the protection of baby and HCPs
  • Most significant difference is the amount of gear your care provider will be wearing!
    • PPE (personal protective equipment) for droplet/contact precautions
  • Cesarean delivery should be reserved for obstetrical intervention (you should not be required to have a C/S just because you are COVID-19 positive)
  • No evidence to avoid delayed cord clamping (DCC), but some centres are promoting this
    • COVID-19 positive or suspected persons may not be offered DCC
  • Hospital birth is recommended for COVID-19 positive or suspected positive persons as cEFM is recommended by the SOGC
  • If you’re planning an elective C-section (repeat or otherwise) this procedure may be delayed if you become sick until such time that you can be considered no longer infectious
  • Some centres are encouraging early epidural, especially if complications are anticipated
    • The reason behind this is to ensure there is time for screening and so things can be done in a safe way (ie not rushed)
  • Some centres are not offering trial of labour after cesarean section (TOLAC)/vaginal birth after cesarean section (VBAC) at this time
    • The reason for this is they don’t want to do things in a rushed fashion
    • There is less likelihood of people forgetting to wear mask etc. when situation is non urgent
  • Water birth or labouring in water with ruptured membranes is being discouraged at this time
  • So for some this does not change plans at all, for others this may be very different then what you had planned

Support people & Visitors

  • There is no provincial standard around this: each centre sets their own visitor policy
  • WHO recommends every woman to have a support person of their choice for their delivery
  • Most hospitals have a one support person in labour policy in effect during COVID-19. This person comes in with you, when you are in active labour (you shouldn’t be in the hospital before then anyway!) and cannot be substituted for someone else
    • The person you bring with you is the person who stays with you
    • You support person cannot come and go, they must stay in the room with you for the duration of the labour and can’t be switched for someone else if they get tired etc.
    • This is done to reduce the exposure risk to everyone on the labour and delivery floor including newborns, pregnant people and hospital staff
  • Many hospitals are requiring this support person to leave within 1-2 hours of the birth (as they now are a visitor)
    • This is also hospital dependent, some centres allow support people to stay, others do not
  • Ask your healthcare provider what the rules are close to the time of delivery
  • Most hospitals currently have a strict NO VISITOR policy in place
  • This means NO visitors will be allowed on postpartum units
  • Some centre will allow the partner/birthing support person to stay after delivery- many do not
    • Partners may be required to leave the hospital 1-2 hours after delivery
  • Expect to be required to wear some sort of PPE (ex. Surgical mask) throughout your hospital stay
  • Why? Physical distancing! People should be staying home, people should be staying distance. This reduces the risk of you or your newborn contracting COVID-19
    • At this time you do not need to bring your own mask, you will be given hospital issued PPE. It is unlikely that outside protective gear will be allowed. If a PPE shortage arises this may change, your midwife or OB should notify you if this is required.
  • All Ontarians should be complying with the current mandate for physical distancing
  • This means no gatherings, no outings, no visitors (except for your HCP, if they make house calls – like midwives!)
  • If an individual doesn’t already live in your home they should not be coming to visit you
  • I know it’s not ideal and it’s okay to grieve the loss of the things you had planned – but the more we can stick together and stay home, the shorter this time will be and the healthier we can all stay!!
  • This is not the time to be looking for loopholes
  • This should last until the mandate for physical distancing is lifted

Baby

  • Of the infants that have been infected, infection was most likely due to close contact with an infected person
    • Infection is pretty unlikely, if you have no contact risks!
  • Illness in newborns and children to date has been mild
  • Most common symptoms in the newborn studied was shortness of breath, with lethargy and fever
  • Outcomes in children are mostly positive!

Postpartum care

  • No evidence to support early bathing of infants
  • Universal isolation of the infant from the birthing parent is not recommended
    • You should still be rooming in with your baby
    • You will be offered different kind of support if you are too sick to take care of your baby
  • Breastfeeding should be encouraged and supported if that is your feeding choice
    • If you are COVID-19 positive or suspected, then excellent hand hygiene and mask for feeding and infant interactions is recommended
  • If you have a midwife or have been in midwifery care before, expect fewer in person postpartum visits than usual (or than was outlined to you at the beginning of your pregnancy)
    • Phone/virtual visits unless in person feeding support/weight checks/newborn exams are necessary
  • If you are in care with an OB- they don’t do postpartum follow-up for baby and you get 1 check-up at 6 weeks
    • Check in with your GP (or whomever is caring for your baby) about what they are doing
    • Much of this care is currently being done virtually
  • The 2 month well-baby visit is recommended in person to start the routine vaccination schedule
  • No routine Pap tests are being performed/run during COVID-19
    • By order of Cancer Care Ontario
    • That is because lab testing space is needed for other more essential things
  • This is really no different than the self-monitoring you will do every day in your postpartum period
  • If you are in midwifery care, you will get a sense of what you should be looking for based on the questions we ask every time we see you
  • Some things to look out for:
    • Bleeding:
      • By 4 weeks postpartum bleeding should be greatly decreased (spotting)
      • Any bleeding that soaks a heavy maxi pad in 30 minutes, or the passage of multiple large clots (bigger than your fist) requires urgent attention
    • Breasts:
      • Cracked or sore nipples?
      • Concerns re: infected areas – requires urgent attention
    • Pain:
      • You will likely be feeling pretty normal by the 4 week mark, depending on the nature of your delivery
    • Vitals:
      • How do you feel? If you’re feeling fairly normal (you will be tired!!!), that reassuring
      • Fever, signs and symptoms of high blood pressure – requires attention
    • Mood:
      • Some feelings of fragility, “baby blues” are common and normal
      • Concerns regarding postpartum depression? Especially in the context of a pre-existing condition –  seek help
  • If in doubt, check it out. Call your midwife or doctor with concerns

Home birth

Even before COVID-19:

  • Hospitals have been breeding grounds for many pathogens and “superbugs”
  • Home birth has been demonstrated to be just as safe as hospital birth for low risk women, with healthy pregnancies, when attended by an experienced provider
    • Safer than hospital birth from the perspective of infectious complications
    • Safer than hospital birth from the perspective of unnecessary interventions
  • Many countries in the world (notably the United Kingdom) recommend out of hospital birth for all low risk women with healthy pregnancies
  • Making the choice for a home birth just because of this might not be the best decision
  • However, if you were still deciding on birthplace this is a good reason to examine the evidence

And now:

  • There are many reasons that home birth is appropriate and a wonderful option for many women!!
    • Any healthy, low risk pregnancy!
  • Many reasons home birth would be supported but should proceed with caution and ample awareness of risks/benefits:
    • Any situation where cEFM (continuous electronic fetal monitoring)is recommended:
      • TOLAC/VBAC
      • Postdates beyond 42 weeks
      • Gestational diabetes
      • COVID-19 (possibly)
  • Many reasons where home birth would be discouraged:
    • You don’t want one
    • If you don’t have a midwife, you can’t have one!
      • Physicians are neither trained, nor licensed to provide out of hospital delivery
    • The CMO (College of midwives of Ontario) does not support midwives to provide home birth before 37 weeks
    • Any contraindications to a vaginal delivery 
    • Any emergent obstetrical complication
    • Make sure you attend a home birth information session if you are deciding where to have your baby
  • May be beneficial by way of social/physical distancing
  • Minimizes the burden on an overstretched hospital
  • Recommended as a way to limit obstetrical intervention and reduce the risk of COVID-19 (and other hospital pathogens) infection
    • Different hospitals may implement different interventions in light of COVID-19 that you would not be subject to at home
      • Ie. early epidural, early cord clamping etc.
  • But….it’s complicated:
    • Midwives are still complying with physical distancing, no visitors, extra people at the birth (every practice will have a different policy around this)
    • Water birth is not currently recommended
    • If you are COVID-19 positive or suspected positive, hospital birth is recommended for cEFM by SOGC – but the evidence supporting this recommendation is weak
    • If anyone is your house is COVID-19 positive or suspected to be they should isolate in a different part of the house from you
    • Your midwife will screen you an the members of your household, and have an informed choice discussion re: what arrangements can be made to help keep all parties safe
    • There is a significant PPE shortage, particularly for midwives, we may not have the supplies to offer home birth and may have to “go where the PPE is” to protect ourselves and our families

Other Questions

  • Non essential procedures are being delayed in general
  • Circumcision may fall into this category
  • Check with your hospital directly
  • Currently hospitals stays are 24 hrs for an uncomplicated vaginal delivery and 48 hrs after cesarean delivery
  • Some c/s patients are offered discharge after 24 hrs but prior to 48 hrs
  • Midwifery clients may be offered early discharge as the midwife will follow up with the client at home to do necessary testing and assessments
  • Check with your hospital directly as procedures may change
  • This varies by clinic
  • Many clinics have increased virtual consultations

Here is a list of Toronto breastfeeding clinics and if they are currently operating: https://www.toronto.ca/community-people/children-parenting/pregnancy-and-parenting/breastfeeding/services/breastfeeding-clinics/

As COVID-19 continues to evolve our healthcare system will adapt and make changes as necessary. Procedures vary by provider and by hospital. Remember to check with your midwife or OB and your hospital to find out what changes may affect your care. Below is a list of hospital resources regarding COVID-19 and pregnancy.

For a full list of resources on COVID-19 and pregnancy go here: http://wombnwell.com/covid-19/

Flint S, Enquist L, Racaniello V, Skalka A. Principles of virology: molecular biology, pathogenesis, and control of animal viruses. 2nd ed. Washington; 2004. Corman VM, Muth D, Niemeyer D, Drosten C. Hosts and Sources of Endemic Human Coronaviruses. 2018;100:163–88.

Andersen KG, Rambaut A, Lipkin WI, Holmes EC, Garry RF. The proximal origin of SARS‐CoV‐2. Nat Med [Internet]. 2020 Mar 17;2–4. Available from: http://www.nature.com/articles/s41591‐020‐0820‐9

Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID‐19 infection in nine pregnant women: a retrospective review of medical records. Lancet [Internet]. 2020 Mar;395(10226):809–15. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140673620303603

Breslin N, Baptiste C, Gyamfi‐Bannerman C, Miller R, Martinez R, Bernstein K, et al. COVID‐19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals.

Qiao J. What are the risks of COVID‐19 infection in pregnant women ? Lancet. 2020;6736(20):760–2.
Liu Y, Chen H, Tang K, Guo Y. Clinical manifestations and outcome of SARS‐CoV‐2 infection during pregnancy. J Infect [Internet]. 2020; Available from:

https://doi.org/10.1016/j.jinf.2020.02.028

Zeng L, Xia S, Yuan W, Yan K, Xiao F, Shao J, et al. Neonatal Early‐Onset Infection With SARS‐CoV‐2 in 33 Neonates Born to Mothers With COVID‐19 in Wuhan, China. JAMA Pediatr. 2020;23(77):4–6.

Lu Q. Coronavirus disease ( COVID ‐ 19 ) and neonate : What neonatologist need to know. 2020;(February):1–4.

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ [Internet]. 2009/09/02. 2009;181(6–7):377–83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19720688

Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned home and planned hospital births in low‐risk women attended by midwives in Ontario, Canada, 2003‐2006: A retrospective cohort study. Birth. 2009;36(3):180–9.

We truly hope that you find this information helpful and use this as a resource throughout the COVID-19 pandemic. Pregnancy can be a challenging time and layering a pandemic on top of that adds to the uncertainty. We are here to reassure you with the information you need and the support you deserve.

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