COVID-19 Management in Pregnant Women

General Principles

Pregnant women with COVID-19 should receive essential antenatal and postnatal care with appropriate precautions, while considering thromboprophylaxis and monitoring for complications including pulmonary embolism and sepsis, as recommended by the British Medical Journal 1, 2
Routine antenatal and postnatal care should continue for pregnant women, with modifications to reduce infection risk; women should attend appointments unless they have suspected or confirmed COVID-19 requiring self-isolation, according to the British Medical Journal 1, 3
Consider differential diagnoses such as pulmonary embolism and sepsis when evaluating pregnant women with COVID-19 symptoms, as suggested by the British Medical Journal 1, 2
After 28 weeks of pregnancy, social distancing should be observed more stringently due to increased vulnerability, as recommended by the British Medical Journal 2, 3
Mental health assessment should be conducted during every consultation, with appropriate referrals made as needed, according to the British Medical Journal 1, 3

COVID-19 increases thromboembolism risk, which is already elevated in pregnancy (hypercoagulable state), as reported by the British Medical Journal and the Journal of Thrombosis and Haemostasis 1, 4
Low molecular weight heparin should be considered for pregnant women with COVID-19, with dosing based on disease severity, timing of delivery, inpatient/outpatient status, and underlying comorbidities, as recommended by the Journal of Thrombosis and Haemostasis 4
Monitor coagulation parameters carefully, noting that pregnancy alters normal ranges, with PT and APTT ratios ≥1.5 used as cut-off for coagulopathy, as suggested by the Journal of Thrombosis and Haemostasis 4
Fibrinogen levels require individualized assessment, with attention to hypofibrinogenemia which can be particularly dangerous in obstetric settings, according to the Journal of Thrombosis and Haemostasis 4

For confirmed COVID-19 cases, refer women for fetal growth surveillance via ultrasound 14 days after symptom resolution, as recommended by the British Medical Journal 1, 2
Carbon monoxide monitoring should be suspended during the pandemic, according to the British Medical Journal 1, 3

Continuous electronic fetal monitoring is recommended during labor for all cases of suspected or confirmed COVID-19, as suggested by the British Medical Journal 1, 5
Healthcare providers must wear appropriate personal protective equipment (PPE) when treating patients with suspected or confirmed COVID-19, which may cause delays in emergency situations, as recommended by the British Medical Journal 1, 5
Nitrous oxide (Entonox) can be used with a single patient microbiological filter, according to the British Medical Journal 1, 5
No specific mode of birth is recommended based on COVID-19 status alone, but birthing pools should be avoided for women with suspected or confirmed COVID-19, as suggested by the British Medical Journal 1, 6

In case of maternal cardiac arrest, high-quality CPR with lateral uterine displacement is essential, and perimortem cesarean delivery should be considered within 5 minutes if indicated, as recommended by the American Heart Association, published in Circulation 7

Breastfeeding is encouraged as benefits outweigh the risks of infection transmission from mother to infant, according to the British Medical Journal 1, 5
Mothers who test positive for COVID-19 and their healthy babies do not require separation, as suggested by the British Medical Journal 1, 5

For pregnant women with COVID-19, individualized VTE risk assessment should be performed considering immobility, fever, dehydration, BMI >30, diabetes, and other maternal risk factors, and low-risk patients should be encouraged to hydrate, mobilize, and control fever, while higher-risk patients may require prophylactic low molecular weight heparin (LMWH) 8
Weight-adjusted prophylactic LMWH should be strongly considered for all hospitalized pregnant women with COVID-19, provided platelet count is >30 × 10⁹/L, no active bleeding, and delivery is not anticipated within 24 hours 8
Prolonged PT and APTT should not be considered contraindications to thromboprophylaxis in COVID-19, as these may reflect acute phase reactants rather than true coagulopathy 8, 9
COVID-19 creates a prothrombotic state superimposed on pregnancy's baseline hypercoagulability, significantly increasing VTE risk 9
Obesity and diabetes are particularly high-risk comorbidities that have been associated with severe thrombotic complications including stroke and pulmonary embolism in pregnant COVID-19 patients 9
D-dimer levels are physiologically elevated in pregnancy, so significant elevations above pregnancy norms should raise suspicion for potential deterioration 8

Check platelet count before any invasive procedures, including neuraxial anesthesia if needed later in pregnancy 10, 11
Consider CT angiography or venous ultrasound if there is rapid respiratory deterioration and/or markedly elevated D-dimer to evaluate for VTE 9

Provide supplemental oxygen if needed to maintain SpO₂ >94%, using face mask rather than nasal cannula to minimize aerosolization risk 12
Ensure adequate fluid intake and nutritional support 8
Acetaminophen (paracetamol) is safe and should be used for fever control 13
NSAIDs may be used if there are no contraindications, despite early concerns about ibuprofen in COVID-19 13
Antibiotics should only be used if there is evidence of bacterial superinfection, not empirically for viral illness alone 12

Continue LMWH for 10-14 days if prescribed for additional risk factors 8
Duration of thromboprophylaxis after discharge should be individualized: 10-14 days for uncomplicated brief admissions, potentially longer for severe disease with very high D-dimer levels 8
Fetal growth surveillance ultrasound should be performed 14 days after symptom resolution for confirmed COVID-19 cases 14

Respiratory rate >20 breaths/minute or increasing dyspnea 12
Signs of preeclampsia (headache, visual changes, right upper quadrant pain) - note that COVID-19 can present with HELLP-like syndrome 9
Decreased fetal movement (though not typically assessed until later in pregnancy) 14
Vaginal bleeding or signs of miscarriage 8

At 9 weeks, fetal monitoring is not yet feasible, so focus is entirely on maternal stabilization 14
Avoid unnecessary radiation exposure, but do not delay indicated radiologic investigations due to pregnancy 14