Read the questions from our series of webinars on COVID19, answered by ISUOG experts.

Medication and Prescribing

What is your position about ACE inhibitors as a potential risk factor for fatal COVID-19?

ESC Council on Hypertension says ACE-I and ARBs do not increase COVID-19 mortality - source. 

Do we have any further information regarding the impact of NSAIDs on disease course?

Anyone with COVID-19 should continue to take any medication they are already taking, unless they are told not to by a healthcare professional.  This includes anti-inflammatories (NSAID) such as ibuprofen, naproxen or diclofenac - source. 

Is Metothrexate therapy safe for COVID patients with extrauterine pregnancy?

We don't know of any data yet. Would need expert consensus.

What about the association of hypertension patients that take ACE INHIBITOR drugs. Is there a more severe clinical outcome?

We don't know of any studies which can differentiate the effect of different antihypertensives on morbidity and mortality in patients with hypertension and COVID. For ISUOG interim guidance click here. For RCOG guidance click here

Do prenatal corticoids in COVID patients worsen the condition?

For preterm cases requiring delivery, we urge caution regarding the use of antenatal steroids  for fetal lung maturation in a critically ill patient, because this can potentially worsen the clinical condition, based on data from MERS, and the administration of antenatal steroids would delay the delivery that is necessary for management of the patient.

Is anti-retroviral treatment recommend? Has it been tried?

If antiviral treatment is to be considered, this should be done following careful discussion with virologists. 

Is there any caution about the use of corticosteroid for fetal lung maturation in the affected mother?

For preterm cases requiring delivery, we urge caution regarding the use of antenatal steroids  for fetal lung maturation in a critically ill patient, because this can potentially worsen the clinical condition, based on data from MERS, and the administration of antenatal steroids would delay the delivery that is necessary for management of the patient.

Obstetric Care

Do you recommend delivery after 37 weeks of gestation even with mild disease?

See more information for healthcare professionals regarding this subject here. 

Do you recommend delivery after 37 weeks?

See more information for healthcare professionals regarding this subject here.

Indications of fetal monitoring?

See more information on this subject here.

Is breastfeeding really safe in pregnant women with confirmed COVID-19?

For the moment information on this subject is limited. We suggest looking through the ISUOG interim guidance and RCOG guidance

What are the recommendation for newborns?

We may need to answer this at the next webinar.

Are fetal scalp procedures safe in COVID patients in the obstetric ward?

Based on limited data, there is no evidence that vaginal delivery increases the risk of vertical transmission. However, I would not recommend FSE in the event of suboptimal CTG. Prompt delivery by Caesarean section is preferred.

Could you please further justify the contraindication of delayed cord clamping?

This is to reduce the exposure of baby to the confirmed/probable/suspected COVID-19 mother as the distance of separation would be less than 1 meter. 

At what gestational age of pregnancy is the termination recommended in a term (for example 37-38 weeks) pregnant woman who is confirmed COVID-19 and candidate for normal vaginal delivery? Do you suggest induction of labor?

COVID-19 infection itself is not an indication for delivery, unless there is a need to improve maternal oxygenation. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the patient, gestational age and fetal condition. In the event that an infected woman has spontaneous onset of labor with optimal progress, she could be allowed to deliver vaginally. Shortening the second stage by operative vaginal delivery can be considered. 

Do you think induction of labour may be indicated in a pregnancy over 36 weeks if the mother is COVID positive and symptomatic, regardless of fetal wellbeing? And over 34 weeks?

COVID-19 infection itself is not an indication for delivery, unless there is a need to improve maternal oxygenation. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the patient, gestational age and fetal condition. In the event that an infected woman has spontaneous onset of labor with optimal progress, she could be allowed to deliver vaginally. Shortening the second stage by operative vaginal delivery can be considered. 

How have you been managing pregnant women approaching term who may have been self-isolating but COVID status not confirmed?

Depends on the level of suspicion, if highly suspected, consider doing the COVID test first. Our turn-around time is a few hours. During that period, an AIIR room is needed. Once the woman is screened negative, she can be downgraded. All our women will be given surgical masks in the ward.

How is the handling of the baby in the postnatal period in COVID-19 for mothers who are not breastfeeding?

Please refer to ISUOG interim guidance for more details: Regarding neonatal management of suspected, probable and confirmed cases of maternal COVID-19 infection, the umbilical cord should be clamped promptly and the neonate should be transferred to the resuscitation area for assessment by the attending pediatric team. There is currently insufficient evidence regarding the safety of breastfeeding and the need for mother/baby separation. If the mother is severely or critically ill, separation appears to be the best option, with attempts to express breastmilk in order to maintain milk production. Precautions should be taken for the cleaning of the breast pumps.

I am asking for an assessment of yesterday's decision on 12 weeks’ quarantine for pregnant women in the UK. Will this mean no ultrasound tests for this group? e.g. tests of the 1st trimester?

This is not the recommendations in other countries.  ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services. Watch this space.

If your patient has severe COVID-19, how often do you need a fetal monitor?

In a severe case of COVID-19, once mother is stabilised, a bedside scan to evaluate fetal growth and AFI can be considered. It is highly likely that this patient will need emergency delivery to improve maternal oxygenation.

Indications of ICU admission of a pregnant women?

Management of COVID-19-infected pregnant women should be undertaken by a multidisciplinary team (obstetricians, maternal–fetal-medicine subspecialists, intensivists, obstetric anaesthetists, midwives, virologists, microbiologists, neonatologists, infectious-disease specialists). You may refer to 2007 Infectious Diseases Society of America/American Thoracic Society criteria for defining severe community-acquired pneumonia.

Indications of termination according to maternal condition?

COVID-19 infection itself is not an indication for TOP/delivery, unless there is a need to improve maternal oxygenation. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the patient, gestational age and fetal condition. 

Is the reason for avoiding GBS screening in suspected cases, due to the concern RE: COVID transmission through vaginal secretions? Any further precautions recommended during labour for health care workers?

There is no data re: presence of virus in vaginal secretions. As there is an alternative to GBS screening, i.e. intrapartum prophylactic antibiotics in high risk cases, clinicians can consider avoiding this procedure.

Is it recommended to do chest x-rays on patients in labor?

Only if they have acute respiratory symptoms with or without fever.

Isolation of the newborn in case of an infected mother?

This is the recommendation of countries in Asia: China, Singapore, HK.

Route of delivery?

COVID-19 infection itself is not an indication for delivery, unless there is a need to improve maternal oxygenation. The timing and mode of delivery should be individualized, dependent mainly on the clinical status of the patient, gestational age and fetal condition. 

Should pregnant woman who test positive perform CT scan in case of mild respiratory disease?

Chest imaging, especially CT scan, should be included in the work-up of pregnant women with suspected, probable or confirmed COVID-19 infection.

PPE

Are you using head covering such as a OR cap when caring for the COVID patient?

In my unit, yes, although this is not in the formal WHO or CDC recommendations.

Can you clarify whether you recommend N95 for delivering physicians or not?

If delivering a confirmed/suspected/probable COVID-19 patient, YES, use an N95 mask as vaginal delivery is a potential aerosolising event and caesarean section also risks exposure to bodily fluids.

Can you elaborate on the fit N95-test?

An N95 mask needs to be fitted annually to ensure it has a good seal for the individual's face. There are generally 2 broad ways to fit an N95 mask - a qualitative and a quantitative method. You should speak to your occupational health department to assist you with the fitting procedure if you have not been fitted. 

When you prolong the use of N95 mask using a paper bag - how long lasts the prolonged use?

It is still for 8 hours and up to 5 uses. This tip is only to prevent wasting a mask from inadvertent soilage when not in use.

I saw a slide about reusing N95. Would you please clarify it further?

N95 and FFP3 respirators are scarce and precious commodities especially during this pandemic. The CDC recommends that an N95 mask may be used for up to 8 hours either continuously or reused intermittently up to 5 times. However, they need to be discarded after aerosol-generating procedures, contamination with bodily fluid, exposure to patient with infectious disease requiring contact precaution or visible damage or if it becomes difficult to breathe through it. Tips to prolong the use of your respirator: use a cleanable face shield over the respirator to prevent surface contamination; hang used respirators in between uses in designated storage areas or in a breathable container such as a paper bag; minimise cross contamination by ensuring masks do not touch each other when stored and that each mask is clearly labelled with the name of the user.

FFP3 mask duration of use is 4 hours according to whose recommendation?

The duration of use of each FFP3 mask needs to be checked with the manufacturer's information sheet. Review of some of the available FFP3 mask information sheets online show that they can be used for up to 8 hours depending on make and model as well as conditions of use. As mentioned during the webinar, you should discard your respirator (FFP3 or N95) after aerosol generating procedures, contamination with bodily fluids, noticeable damage on the respirator, if it becomes hard to breathe through and if you have been in close contact with a patient who has an infectious disease that requires contact precaution.

Give us advice to prepare our delivery rooms. Do you recommend PPE in case of intrapartum fever?

Intrapartum fever is a common symptom. On its own, I do not think there is sufficient evidence currently to recommend the use of PPE although high standards of general preventive measures need to be practiced. If your patient has associated acute respiratory symptoms, treat the patient as a suspected case of COVID-19 until proven otherwise, in which case we would recommend use of PPE during her care. 

How often do we need to change surgical masks if is stock is short? How often should surgical masks be changed in everyday normal work on a birth suite with no "known cases" in labour or in an antenatal clinic?

The FDA standards do not address the duration of use of surgical masks but has advised that they are intended for single use. Currently, many centres practice the use of a single surgical mask for the duration of the whole day IF the mask is not visibly damaged or soiled when it needs to be discarded. You should also change your mask if breathing through the mask becomes difficult.  

For healthy, COVID negative patients which personal protective equipment is recommended for health care workers at this time?

In Singapore, Hong Kong and many parts of East Asia, we recommend wearing a surgical mask in areas of high risk such as hospitals and other clinical areas. 

Is a surgical mask adequate, or do you recommend P3-masks for healthcare workers during active pushing in labor?

We recommend using a FFP3 or N95 respirator if attending to a delivery of a confirmed/probable/suspected COVID-19 patient. For all other patients, we recommend the use of a surgical mask as in all other clinical areas. 

You recommend surgical masks and gloves in outpatient obstetrical outpatient clinic?

Surgical masks, yes. Non-sterile gloves are not yet in our recommendation but good hand hygiene needs to be observed.

Rationalising and Organising Services

Do obstetricians or midwives in your experience need to help in other wards? ICU? Medicine ward?

At present, a few junior doctors from O&G have been sent to help in A&E which has seen a surge in number of attendances. This situation is similar in other specialties including repatriation of manpower from radiology to A&E. Senior obstetricians and midwives remain in their usual work as there is no reduction in obstetric services in my unit, only reduction of elective gynaecology services.

Are first trimester screening and organ screening are still done regularly in Hong Kong, as long as the patient doesn't have symptoms?

Yes, as long as they have booked the appointment and screened negative for high risk in TOCC; in HK, all patients and healthcare workers wear appropriate surgical masks. This allows such important services to continue.

Do you think NICU nurses will be re-deployed to cover adult ITU? Should this be allowed to happen?

I certainly hope not as we expect NICU to be as busy as ever as obstetric workload will be no different than prior to the pandemic. In addition, there may be neonates (newborns or within their 1st year of life) who will be affected by COVID-19 who might need NICU. These nurses are very much needed in NICU and in my experience, they are usually already traditionally understaffed for their workload.

Do you think that first trimester sonography/morphology and third trimester screening sonography should be stopped?

ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services. 

How did you structure the patient flows in the hospital for patients, clothing wastes?

We suspended visitors and encouraged limited number of accompanier for patients who attend for clinics. We reduced non-emergency services and avoided crowding. Provide adequate manpower in the triage area and avoid over-crowding. If there is semi-urgent TOCC positive cases, find a designated area to see them and discharge them from clinic as soon as possible. Soiled closing is well tied in appropriate bags during transport.

Is there any advice on hospital flow (patients, staff, waste, clothing, instruments)?

Please refer to ISUOG Safety Committee Position Statement:
''The safe performance of scans in obstetrics and gynecology and equipment cleaning in the context of COVID-19" . ISUOG is drafting a consensus statement with regard to prioritization of obstetric ultrasound services.

Our maternity ward is in a building apart from the main hospital with ICU, is it best for the pregnant woman tested positive that need to be inpatients to be at the maternity or in the hospital area designated to COVID patients?

It depends on the severity of COVID-19. Management of COVID-19-infected pregnant women should be undertaken by a multidisciplinary team (obstetricians, maternal–fetal-medicine subspecialists, intensivists, obstetric anesthetists, midwives, virologists, microbiologists, neonatologists, infectious-disease specialists).

What about gynaecological elective work, OP and OTs?

For operation, we try to conserve PPE to high risk area of hospital and avoid usage of PPE during intubation and extubation procedure for non-life saving or non-malignancy cases. Therefore, about 50% reduced in elective surgery. For outpatient services, we do not introduce extra work to contact all patients, but about 50% defaulted due to worry to come to hospital. In outpatient clinics, some clinics can be combined to save manpower and resources.

Was starting with gynecological procedures under regional anesthesia only, only to spare material for ventilation?

Meanwhile, we need PPE to protect Anaesthetists and the related health care worker during intubation and extubation as these are aerosol generating procedures. Performing surgery under regional anaesthesia may help to conserve the PPE and not an inferior option to patient either. 

Staff - Testing and Isolation

Does a person who is COVID-19 positive and isolated at home need treatment?

This is the subject of ongoing trials, nil published for pregnant women to date.

Are you restricting staff with their own chronic health conditions from treating these patients? (ie: Hypertension or Diabetes etc)

I do not have staff with significant health problem. Priority can be set in the whole organization and each unit with consensus from all colleagues. Generally, staffs who are pregnant or have significant chronic medical problems will have a low priority to be deployed.

If a healthcare worker has contact with someone positive but is asymptomatic what do you do? Test healthcare worker or quarantine them?

If a healthcare worker has had significant unprotected contact with a confirmed  COVID-19  case, we recommend quarantine for 14 days and testing if/when symptomatic. 

In many countries, such the NL, health care workers are not tested, even in case of (light) symptoms and they are seeing daily patients. What do you think of this choice?

We recommend screening and testing healthcare workers in the same criteria as you would with everyone else. Testing facilities need to be made accessible to both the public and especially to healthcare workers to ensure early diagnosis and institution of appropriate infection control measures, including quarantine.

Staff - Wellbeing and Safety

Does a person who is COVID-19 positive and isolated at home need treatment?

This is the subject of ongoing trials, nil published for pregnant women to date.

Should all healthcare providers’ vacation or holidays be suspended to have more manpower?

It depends on the stage of evolvement of COVID-19 in your country and if staff may need to be quarantined after contact with patients but without adequate protective measures.

I'd like to know what the recommendations are for pregnant doctors and sanitary team. Do we need to stop working or is it safe to continue with the normal practice taking the proper safety measures?

At present, as there is no apparent evidence from the limited data that pregnant healthcare workers are more susceptible to COVID-19 than their non-pregnant colleagues, we recommend continuing with normal work practices but adhering strictly to the infection control and prevention measures.

Is it a good idea to split the staff within units to have a "reserve" team just in case one team is "incapacitated" by exposure?

Yes. Vital healthcare services need to be preserved. By reserving "clean" teams or teams that do not meet the same patient, services can remain in function even in the event of unexpected unprotected exposure to a COVID-19 case.

So basically lunch breaks are individual. How you deal with that at the designated spaces?

In canteens, all people should sit on one side of the table only so there will not be face-to-face sitting. Or in smaller room, use dividers to separate the table space. 

Some teams in France have divided. Half of the staff stays home for 14 days, then comes to work for 14 days, to allow quarantine and diagnosis of medical staff.

This is still reasonable if there is adequate manpower and worry about  staff being exposed without adequate protection.

What was HRs policy for staff with comorbidities and pregnant doctors?

They have a lower priority to be deployed to work in high risk area.

 

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