POST DELIVERY/NEONATAL MANAGEMENT OF WOMEN WITH COVID-19 INFECTION
Delayed clamping of the umbilical cord remains a controversial issue. ISUOG and FIGO guidelines both recommend prompt clamping of the cord and transfer of the neonate to the resuscitation area for evaluation by the paediatric team.8, 9 In contrast and in recognition of the lack of evidence to suggest otherwise, the RCOG continue to recommend delayed cord clamping.7 According to WHO, delayed cord clamping is highly unlikely to increase the risk of vertical transmission of pathogens even in the context of maternal infection.26 Furthermore, to date, no positive RT-PCR results have been found in the amniotic fluid, placenta or cord blood of the studied population. In the UKOSS cohort, 6 infants born to 244 women hospitalised with COVID-19 infection tested positive for SARS-COV-2 RNA, with only one infant requiring admission to the neonatal intensive care unit. Another systematic review including 256 infants born to women with COVID-19 infection reported only 4 who were RT-PCR positive for SARS-COV-2 RNA within the first 36 hours of birth.11Again, samples from their cord blood, placenta and amniotic fluid were all negative and all 4 infants had an uncomplicated recovery. Therefore, there is no conclusive evidence at present of fetal infection via intrauterine vertical transmission. Considering the well-known clinical benefits to the neonate of delayed cord clamping, there is some concern amongst experts that recommending otherwise in women with COVID-19 in the absence of sufficient evidence could be harmful.
There is currently limited evidence regarding the safety of breastfeeding and the need for mother-baby separation. In view of this, all guidelines advise against universal isolation of neonates born to mothers with COVID-19 infection and that it may only be appropriate if the mother is critically ill. An alternative to separation suggested by FIGO and ISUOG guidelines is ‘co-rooming’ where the baby’s cot is kept at least 2 metres from the mothers bed.8, 9 The main concern of breastfeeding is the risk of transmitting SARS-COV-2 from the mother to the baby via respiratory droplets rather than the breast milk itself. All samples of breast milk have so far tested negative for SARS-COV-2.11 The RCOG, ISUOG and FIGO guidelines all advise that those who wish to breast feed, should the maternal condition allow, continue to do so. However, precautions should be taken such as hand washing and the use of a surgical mask by the mother to prevent viral spread to the baby.7-9
The highest risk of venous thromboembolism (VTE) is during the first six weeks of the postnatal period with a 12-fold increase compared to the non-pregnant, non-postpartum population.27Furthermore, emerging evidence shows that COVID-19 is associated with significant coagulopathy namely disseminated intravascular coagulation leading to VTE.28 Although the risk remains highest in those who are critically unwell, representing only about 5 percent of the population with COVID-19, the impact on VTE risk in those with mild to moderate disease remains unknown.28 Thus, the RCOG recommend that, following birth, all women with COVID-19 infection should be discharged with at least 10 days of treatment with low molecular weight heparin or longer should additional risk factors be present.7