Running title: Rethinking perinatal care and CVOID19 pandemic.
The COVID19 outbreak has affected many aspects of people’s lives,
including those of pregnant women. Apart from social-distancing,
prohibition of assemblies, isolation, quarantine and many other imposed
measures, there are restrictions on access to planned medical
consultations, diagnostic procedures and interventions. These
restrictions may both, directly and indirectly, disturb the stability of
healthcare systems.
The previous commentaries presented in this journal have discussed the
novel virus and the readiness of obstetricians for dealing with COVID 19
positive mothers. [1][2] But what about the rest? What about
those without symptoms, that in some countries are home on lockdown? Are
we ready to take our pregnant women completely “online”? Do they all
qualify? Is it safe? Is it efficient? Is it ethical? What if something
goes wrong? Are there laws protecting both sides: the patient and the
medical professional?
Pregnant women are a specific group of patients. The majority of them
are young women without co-morbidities. But pregnancy is a time of
increased medical supervision aimed at achieving the best perinatal
outcome, reduction of both maternal and neonatal morbidity and
mortality. Pregnancy is a risk factor of COVID-19
infection, especially in the 3rd trimester [3]. Adequate antenatal
care according to both national and international standards may be
affected by several factors: healthcare providers limiting consultations
to those classified as urgent both in outpatient and inpatient
facilities, limited access to medical facilities due to restrictions of
travel and transport. All these restrictions have been imposed in good
faith as a measure of social distancing. But it has to be noted that as
a result, women may be reluctant to visit medical facilities because of
fear of contracting the virus, therefore voluntarily waiving their right
to access antenatal visits.
Statements have been published regarding the use of personal protective
equipment (PPE) aimed at minimizing the risk of exposition of medical
personnel. As reality shows, access to PPE is limited even in the most
efficient health systems [4]. This may also be a burden in the
provision of optimal antenatal care in some settings.
COVID-19 pandemic has reached more than 200 countries [5]. The
mortality rate varies and depends mainly on age and comorbidities. The
highest is recorded in countries such as Italy and Spain [5]. The
average reported by WHO is 3.4%. Recent reports indicate a
significantly lower mortality of 0.66% [6] because previous
registries have not included asymptomatic patients.
Adequate antenatal care is a standardized medical process aimed at
achieving perinatal results characterized by a low percentage of
prematurity, low maternal and fetal mortality and morbidity. The
preventive measures implemented over the years helped prevent in many
cases, serious complications. In recent years, our country Poland has
achieved the lowest maternal mortality in the entire European region and
one of the lowest perinatal mortality rates.
These results can be attributed to doctor or midwife assisted antenatal
visits every 3-4 weeks and recommended 3-4 ultrasound examinations in
each pregnancy. This system was built on experience, research and
organization of a national perinatal care system. We fear that the
failure of the system to perform adequately in the light of the imposed
restrictions may, in a short time, lead to a deterioration of perinatal
results. This the least will be caused by COVID-19 infections in
pregnancy. According to previous reports, the course of coronavirus
infection is not worse than in the non-pregnant population of the same
age [7]. Particular attention should be paid to pregnant women with
co-morbidities because those are at most significant risk of
complication both with and without coronavirus infection.
When managing a pregnancy, unassisted 4-5 weeks may have a substantial
impact on the outcome. Non-adherence to the right timing of
acetylsalicylic acid prophylaxis, vaginal progesterone treatment,
glucose tolerance test or anti D immunoglobulin injection, can lead to
significant complications. Women that suffer from pre-pregnancy
morbidities such as hypertension, diabetes, renal problems, obesity are
in these times at risk of an even higher risk of adverse outcome due to
reduction in surveillance. In their case, there is a need for more than
less scrutiny. In this group of women, on the one hand, we fear that
restricted access to health care facilities may lead to deterioration of
control of blood pressure values, glucose levels or excessive weight
gain. On the other hand, they may become exposed to the coronavirus,
which again in this group may lead to an adverse outcome, because these
women are at higher risk of severe complications associated with the
viral infection.
As mentioned before, without fully adhering to the recommended protocols
for both low and high risk, but especially high-risk pregnancies, the
goals of optimal perinatal care cannot be achieved. In the time of the
pandemic adherence to protocols is put to the test, and although interim
protocols are published by national and international societies to
adjust means to the measure, it may not be enough. [8] Two reports
[9,10] show the impact of co-morbidities on the percentage of severe
cases among infected with COVID-19 pregnant women. In a study from
China, 38 women infected with SARS-CoV-2 were analyzed; none of them had
pre-pregnancy comorbidities. Of those women, 3 developed gestational
diabetes and one hypertension and one preeclampsia during the course of
pregnancy. In the New York group, more than 41% demonstrated associated
diseases such as asthma, chronic hypertension and type II diabetes. More
than 60% of women in the New York group was diagnosed with obesity – a
factor neglected in the China group (Table 1). These factors could have
a decisive impact on the reported differences regarding the course of
the COVID-19 disease, notably since the age of the patients did not
differ based on the published data. Analysis of these two studies shows
that the course of the viral infection was quite different. In the study
group from China, no severe and critical events were observed, and for
women in New York, they totalled 14%. From the WHO report from all
provinces of China in which 147 pregnant women were analyzed, 8% of
severe cases and 1% of critical cases were reported [11]. Despite a
relatively small group, these results show that co-morbidities,
including obesity, like in the non-pregnant population, decide about the
course of the disease in a given age group.
Restrictions of access to routine care, fear of exposition, deliberate
avoiding of contact with medical personnel, isolation and quarantine
orders, and many other factors can lead to hindered pregnancy
surveillance. If affecting weight gain, blood pressure and diabetes
control in high-risk groups, it may, as a consequence, affect perinatal
outcome regardless of COVID-19 infection.
The current situation related to the pandemic requires an intensified
effort from medical personnel caring for pregnant women. In many cases,
new forms of medical care are implemented, such as telephone and video
consultations. This cannot always replace traditional perinatal visits
but often is a necessity. RCOG warns their pregnant patients to always
discuss with their medical professional the decision about not attending
their prenatal visit. [12] Regular monitoring of pregnancy is
crucial to achieve an optimal outcome. It is the medical community’s
responsibility on all levels (local, national, international) not to
allow the burdens resulting from epidemiological restrictions to impact
negatively the perinatal results achieved thus far.
At the beginning of this commentary, we have asked a series of
questions. We do not have answers to them. COVID-19 may be the first
pandemic in the modern world, but most probably it is not the last. We
do not know and cannot tell for how long this situation is going to
continue. We propose to begin a discussion of how this can be managed
best. Perhaps this should prompt new ideas of how to incorporate
telemedicine and artificial intelligence into obstetric practice. The
proposed solutions, of course, should be followed by new protocols and
laws protecting both the patient and the medical professional.