A twin challenge to handle: COVID‐19 with pregnancy

Dear Editor,

We acknowledge Jiao et al's concern regarding the great need of giving special attention to the pregnant patients during a pandemic period like the current COVID‐19 crisis. ¹ Although Jiao et al discussed the concept of actively suspecting and monitoring such patients, together with their follow‐up starting from early and middle pregnancy, we still believe that recommendations and guidelines of approaching a pregnant patient affected by COVID‐19 should be discussed in more detail.

The recent outbreak of SARS‐CoV‐2 has been extremely challenging for all sectors of healthcare. COVID‐19 patients with pregnancy are special populations who need excellent care and support. However, very little is known regarding the guidelines on how to approach to pregnant patients suffering from COVID‐19.

We agree that there is a scarcity of data, but at the same time, we should acknowledge the excellent and prompt response by the World Health Organization (WHO) and the Chinese Working Committee on Perinatal and Neonatal Management for the Prevention and Control of the 2019 novel coronavirus infection. ² , ³ Both organizations have issued interim guidance or advisory with recommendations specific to pregnant women. ² , ³

Individual expert opinions are also pouring in from all corners of the world, giving the recommendations based on their institutional experiences. ⁴ , ⁵ Favre et al ⁴ from Lausanne University Hospital, Switzerland, published an algorithm describing the steps of how to approach a pregnant woman with SARS‐CoV‐2 exposure. They recommended performing reverse transcription‐polymerase chain reaction (RT‐PCR) for SAR‐CoV‐2 from deep nasopharyngeal and oropharyngeal mucosa in the appropriate clinical settings. If pregnant patients are asymptomatic, they are recommended to quarantine themselves at home until the results of RT‐PCR are available. On the basis of the results, if the test is negative, there is no need for further isolation, but if the test results are positive, they can still be isolated at home for 14 days with close monitoring of mother and regular fetal surveillance by ultrasound and doppler studies. In the case of symptomatic COVID‐19 patients, monitoring at the hospital with isolation under negative pressure is recommended. Maternal and fetal surveillance should continue while the patient is in hospital and waiting for further test results. Further management involves appropriate decision‐making based on the trimester of the patient, fetal well‐being, and maternal symptoms. It is important to note that computed tomography of the chest is an essential modality to evaluate pulmonary symptoms of COVID‐19 patients, and preliminary guidelines recommend the same due to the minimal risk of radiation exposure to the fetus. Also, there is no guideline regarding antiviral therapy because we still do not have any specific antiviral drugs for COVID‐19 pneumonia. Liang et al ⁵ recommended that lopinavir/ritonavir combination could be considered as it is safe to use in pregnancy. Similarly, corticosteroids are not generally recommended in COVID‐19 pneumonia (except ARDS), but if required in a case of preterm labor, intramuscular betamethasone injections can be given for fetal lung maturity.

We appreciate the comment by Jiao et al ¹ on the recent case series of 9 COVID‐19 pregnant patients by Chen et al. ⁶ Also, Chen et al did check their patients for SARS‐COV‐2 virus in multiple body fluid samples like amniotic fluid, cord blood, breast milk samples, and neonatal throat swab, and none of these samples tested were found positive for SARS‐CoV‐2. They did not check vaginal linings for SARS‐CoV‐2 viral shedding; hence, transmission during delivery was not confirmed. A much bigger case series by Liu et al's study showed that 11 out of 13 pregnant patients had complications requiring emergency C‐section in five patients, whereas the other six patients had preterm labor. ⁷

This is the third coronavirus outbreak of the 21st century. ⁸ , ⁹ Although our understanding regarding the current outbreak is limited, studies conducted during MERS and SARS outbreaks can help us sail through this pandemic. ¹⁰ , ¹¹ , ¹² We appreciate that Jiao et al attempted to correlate the maternal outcomes and fatality of current COVID‐19 pandemic with the previous similar coronavirus outbreaks. Besides Wong et al's study on pregnant patients affected with SARS (2009), as mentioned by Jiao et al, there are few more studies that we would like to discuss to complement the topic with more concrete data. ¹⁰ , ¹¹ Lam et al performed a comparative study on patients infected with SARS (2009)—10 pregnant vs 40 nonpregnant patients. The study confirmed that pregnant patients (three deaths) had poorer outcomes as compared (P = .006) with nonpregnant ones (no deaths). Pregnant patients developed more complications, like a renal failure (P = .006) and DIC (P = .006), as compared with nonpregnant patients. ¹⁰ Similar comparative studies are lacking as of now for COVID‐19 confirmed pregnant patients; hence, it is difficult to comment definitively on the basis of available data, but we expect to have more data on COVID‐19 pregnant patients in near future to study such outcomes. Table 1 mentions the three major studies from three major outbreaks—COVID‐19, ⁷ MERS, ¹¹ and SARS ¹² —for better understanding. On the basis of these studies, we can conclude that the mortality rate in SARS‐infected pregnant patients, as reported by Lam et al (reported mortality rate 30%) and Wong et al (reported mortality rate 25%), was almost two to three times more than in SARS‐infected nonpregnant population (reported mortality rate 9%‐10%). ⁷ , ¹¹ , ¹²

Table 1.

Description and comparison of various recent studies on COVID‐19, MERS, and SARS

Parameters		COVID‐19 (2019‐2020)	SARS (2002‐2003)	MERS (2012)
Author et al		Liu et al 7	Wong et al 12	Alfaraj et al 11
Study reported from		First Affiliated Hospital of Sun Yat‐sen University, Guangzhou, China	Princess Margaret Hospital, Hong Kong	Corona Center, Prince Mohammed Bin Abdulaziz Hospital (PMAH), Ministry of Health, Riyadh, Saudi Arabia
Study period			1 February 2003 to 31 July 2003	Medline search 1 January 2012 to 31 July 2016
No. of patients		13	12	11
Trimester at presentation		1st trimester ‐ 0	1st trimester‐ 7 patients	1st trimester ‐ 1
		2nd trimester‐ 2	2nd and 3rd trimester (all patients were >24 wk) ‐ 5 patients	2nd trimester‐ 5
		3rd trimester ‐ 11		3rd trimester ‐ 5
Need for C‐section		5	4	4
Pregnancy outcome		13 outcomes	12 outcomes	11 outcomes
Miscarriage		0	4	2
Preterm delivery		6	4	3
Term delivery		4	1	6
Recovered without		3	3	0
Maternal mortality		0	3 (25%)	2 (27%)
Newborn mortality		1	0	3
Vertical transmission		0	0	NA

Last but not the least, we also feel the pain of the Jiao et al when they mentioned about the sorrowful state under which pregnant medical staff, nurses, and doctors, especially from developing nations, have to continue working during the infective crisis, exposing themselves and their in utero babies during a crucial phase of intrauterine growth. To attest the same, we hereby mention a report on two Chinese physicians who had COVID‐19 exposure during their pregnancy and had to undergo C‐section. ¹³ Fortunately, baby and the mother in both cases did not suffer from any peripartum complication. Current literature on COVID‐19 pandemic is rapidly evolving and hence we expect more revisions. ¹⁴ , ¹⁵

In conclusion, pregnancy with COVID‐19 disease is a special scenario that needs a good understanding of the pathophysiology of this disease. Training the obstetricians based on the current recommendations and previous experiences would ensure the appropriate care of this subset of the population.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.