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ACOG Provides Guidance to Healthcare Practitioners Whose Patients Are “At-Risk” For Coronavirus Disease-2019

Written by: Ryan Donihue, Esq.

With the focus of the global pandemic principally on older adults and those who have serious underlying medical conditions (e.g., heart disease, diabetes, asthma and lung disease), another significant group of individuals have essentially been left out of the discussion who are at an even higher risk for developing severe illness from Coronavirus Disease 2019. This group consists of pregnant women and their unborn child.

According to the most recent data from the National Vital Statistics Reports, there were 3,791,712 live births in the United States in 2018.[1] While the number of live births and pregnancies have been trending slightly down over the past four years, the number of pregnant women ages 40 to 44 years old have actually increased.[2] While women are already suspectable to a whole host of complications naturally associated with pregnancy (e.g., gestational diabetes, hypertension, infections, preeclampsia, preterm labor), with the inclusion of advance maternal age these pregnancies are at an even higher risk of also developing certain birth defects caused by pre-existing genetic disorders, chromosome problems such as Down syndrome or other maternal-fetal complications. Now, add to this mixture exposure and possible contraction of Coronavirus Disease 2019 (“COVID-19”) during the pregnancy.

According to the Centers for Disease Control and Prevention (“CDC”), it is not currently known at this time if pregnant women have a “greater chance of getting sick from COVID-19 than the general public nor whether they are more likely to have serious illness as a result.”[3] Additionally, the CDC has reported that it is “unknown as to whether pregnant women with COVID-19 can pass the virus to the fetus or baby” or “what, if any, risk is posed to infants of a pregnant woman who has COVID-19.”[4] While the CDC has made the exact same recommendations to pregnant women as to the general public as to how to attempt to avoid infection (specifically, cover your cough; avoid people who are sick’ and clean your hands often using soap and water or alcohol-based hand sanitizer), nothing has been able to be specifically identified or targeted to pregnant women.

On March 13, 2020 The American College of Obstetrician and Gynecologists (“ACOG”) issued a Clinical Guidance, Practice Advisory pertaining to COVID-19 in order to assist healthcare practitioners in the management and treatment of obstetrical patients during this pandemic.[5]  At the outset, ACOG has stated “At this time, very little is known about COVID-19, particularly related to its effect on pregnant women and infants, and there currently are no recommendations specific to pregnant women regarding the evaluation or management of COVID-19.”[6] ACOG goes on to state that pregnant women are “known to be at greater risk of severe morbidity and mortality from other respiratory such as influenza and SARS-CoV. As such, pregnant women should be considered an at-risk population for COVID-19.”[7] With limited data available or confirmation that there was relationship to maternal infection, ACOG further stated that “adverse outcomes (e.g. pre-term birth) have been reported among infants born to mothers who tested positive for COVID-19 during pregnancy.”[8] Based on the information known to date, pregnant women should be considered an increased “at-risk” group for developing complications associated with COVID-19.

With social distancing be implemented and private practices potentially being closed for extended period of time, ACOG recommends that obstetricians, maternal fetal medicine specialists and healthcare practitioners should be aware of the “unintended impact they may have, including limiting access to routine prenatal care.”[9] These prenatal healthcare providers should “ensure that patients with certain high-risk conditions are provided necessary prenatal care and testing when needed.”[10] Additionally, it is the recommendation of ACOG that a plan be created to address the possibility of a decreased healthcare workforce; potential shortage of personal protective equipment; limited isolation rooms; and maximize the use of telemedicine across as many aspects of prenatal care as possible.[11]

While there is currently no way to confirm whether a pregnant patient has COVID-19 or some other condition (e.g., flu, seasonal allergies, SARS-coV, MERS-CoV, etc..) without laboratory confirmation, ACOG recommends that obstetricians, maternal fetal medicine specialists and healthcare practitioners should be “vigilant” in obtaining from every patient the following: (1) a detailed travel history as part of the medical history intake; and (2) a history of exposure to people with symptoms of COVID-19, including pregnant women who present with a fever or acute respiratory illness.[12] In order to assist these healthcare providers, ACOG in conjunction with the Society for Maternal-Fetal Medicine have also published an Algorithm to assist practitioners in immediately evaluating and treating pregnant patients with known exposure and/or those symptoms consistent with COVID-19. Obstetricians, maternal fetal medicine specialists and other healthcare practitioners with pregnant patients under their care should read and be familiar with this Algorithm even though this guidance may evolve over time and become out-of-date as new information pertaining to pregnant women and COVID-19 becomes available.

For those pregnant women who present with a fever or acute respiratory illness, it is the recommendation of ACOG that the CDC’s “Interim Clinical Guidance for Management of Patients with Confirmed 2019 Novel Coronavirus (2019-nCOV) Infection” and “Evaluating and Report Persons Under Investigation (PUI)” be followed by the healthcare practitioner.[13] Additionally, ACOG strong suggests that “healthcare practitioners should immediately notify infection control personnel at their healthcare facility and their local or state Health Department in the event of a PUI for COVID-19.[14] By following these recommendations, healthcare practitioners will be guided by the best available information and knowledge available to date.

With COVID-19 just starting to raise its ugly and unprecedent head in the United States, it cannot be stressed enough that pregnant women should be considered to be an included in the increased “at-risk” group for contracting COVID-19 and the number of  cases within this population will only continue to rise over time. Credit must be given to the healthcare practitioners and first-responders who are taking the lead in order to affirmatively and aggressively take steps to understand, identify, diagnose and eventually treat this complicated pandemic. While this ever-evolving process continues, obstetricians, maternal fetal medicine specialists, and other healthcare practitioners treating their patients should continue to be aware, educate and implement into their practice the recommendations set forth by ACOG, Society for Maternal-Fetal Medicine, and the CDC as new information continues to be available and evolve over time.

[1] National Vital Statistics Reports, Volume 68, No. 13, Births: Final Data for 2018 (Nov. 27, 2019)

[2] Id.

[3] Centers for Disease Control and Prevention, Coronavirus Disease 2019 (COVID-19), Pregnancy &
Breastfeeding,
(2020), at http://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html.

[4] Id.

[5] The American College of Obstetrician and Gynecologists, Practice Advisory, Novel Coronavirus 2019
         (COVID-19) (March 2020).

[6] Id.

[7] Id.

[8] Id.

[9] Id.

[10] Id.

[11] Id.

[12] Id.

[13] Id.

[14] Id.

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