Re: From the frontlines of COVID–19—how prepared are we as obstetricians? A commentary

Abstract

Sir, We read with great interest the recent article by Chua et al. published in the March issue of BJOG regarding SARS-CoV-2 infection during pregnancy and proposed guidelines.1 We hereby would like to discuss a few additional and essential points for managing pregnant patients suffering from COVID-19 during the perinatal period. Chua et al. did not mention any recommendations regarding role of imaging studies for pregnant patients with COVID-19. As per the literature available, if medically indicated, computed tomography (CT) of the chest should be performed for pregnant patients with COVID-19, as the risk of radiation exposure to the fetus is not high.2 Also, recent studies have shown CT of the chest as having a higher sensitivity (98%) compared with reverse transcription polymerase chain reaction (RT-PCR) (71%). Chua et al. rightly mentioned that there is no definitive antiviral drug for pregnant patients suffering from COVID-19. Amongst the antiviral medications available, the combination of lopinavir and ritonavir (LPV/RTV) is preferred, considering its safety profile in pregnancy. Chua et al. did not mention the stand of corticosteroid therapy in their guidelines. We would like readers to note that, in general, steroids are not indicated as a treatment for COVID-19 pneumonia for two major reasons: there is a concern that steroids delay viral clearing from the body and can cause lymphopenia, which has been found to be a poor prognostic factor in COVID-19 patients.1, 2 There are two major indications for using steroids that obstetricians should be aware of the short-term use of methylprednisolone (1–2 mg/kg/day for 3–5 days) to reduce lung inflammation and to prevent acute respiratory distress syndrome (ARDS) in the mother, and the administration of intramuscular betamethasone to promote fetal lung maturation when preterm delivery is anticipated.1, 2 With regards to breastfeeding, newborn isolation is a must for at least 2 weeks, but it is not clear whether pumped breast milk can be fed to the baby or not. Chua et al. discussed the case series of nine patients reported by Chen et al.1 Another case series in Liu et al.'s study showed that 11 out of 13 pregnant patients had complications, requiring emergency caesarean section for five patients and with the other six patients undergoing preterm labour.3 Although this is certainly an alarming result, and indicates that pregnancy predisposes women to more complications from COVID-19, compared with non-pregnant patients, none of the major retrospective studies available have mentioned pregnancy as a poor prognostic factor in patients suffering from COVID-19. It is too early to make any assessment about the role of pregnancy and the outcome of COVID-19 disease in terms of pregnancy outcome, maternal and fetal mortality, however. Lam et al. have completed a comparative study on severe acute respiratory syndrome (SARS), and confirmed that pregnant patients had more complications, such as renal failure (P = 0.006) and disseminated intravascular coagulation (DIC; P = 0.006), compared with non-pregnant patients.4, 5 Similar comparative studies are lacking for COVID-19 in pregnancy, and hence it is difficult to comment definitively based on the data available, but we expect to obtain more data on pregnant patients with COVID-19 for the study of such outcomes in the future.6, 7

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