COVID-19 review of national clinical practice guidelines for key questions relating to the care of pregnant women and their babies

Coronavirus disease (COVID-19) is caused by a new strain of Coronavirus (SARS-CoV-2) discovered in 2019 and not previously identified in humans. Common symptoms include fever, cough, and shortness of breath. On March 11, the World Health Organization (WHO) announced the current COVID-19 outbreak as a pandemic. Currently there are more than 3,517,345 confirmed cases globally (data from May 6, 2020) with the numbers increasing rapidly every day. However, available data on the effects of COVID-19 on pregnancy, childbirth and breastfeeding are sparse.

What is the issue and why is it important?
Many clinicians and pregnant women with their families are facing similar questions about the care and wellbeing of women and their babies with confirmed or suspected Covid-19.  

We believe it is important to identify, collate and summarise national clinical practice guideline recommendations that address important questions. This would help busy clinicians, and pregnant women, to see quickly what other countries are recommending for key clinical questions and help inform their decisions. 

What did we do?

We developed a protocol to guide this work but in summary….

  • We carried out a rapid prioritisation exercise to identify a short list of 14 key clinical questions
  • We identified countries with more than 10,000 cases of Covid-19 on 10 April 2020 (19 countries)
  • We identified reviewers from each of these 19 countries from our pool of Cochrane authors, editors, and personal contacts.
  • Two reviewers from each country searched for country-specific clinical practice recommendations and extracted data independently relating to the 14 key clinical questions
  • We collated country-specific clinical practice recommendations relating to the key clinical questions by the categories of (i) yes (ii) consider (iii) no (iv) further research needed/insufficient evidence to recommend (v) not mentioned/no guideline available (vi) unclear (vii) contradictory guideline(s) within country.
  • We explored the level of consensus in recommendations for each question across countries  by looking at the number of countries within which a guideline was available that addressed the target question(s) i.e., for each question, we excluded  countries in which there was no guideline or the guideline did not address the specific question or where guidelines within countries were contradictory).
  • We set consensus levels at 80% i.e., where 80% of countries with a guideline that addressed the question made the same recommendation.

What did we find?

For pregnant women who are COVID-19 positive, we identified consensus that

  • A surgical mask or N-95 respirator should be worn during hospital appointments
  • Vaginal birth is not contraindicated
  • Epidural/spinal analgesia is not contraindicated

For pregnant women who are symptomatic but COVID-19 status unknown, we identified consensus that

  • A surgical mask or N-95 respirator should be worn during hospital appointments
  • Vaginal birth is not contraindicated
  • Epidural/spinal analgesia is not contraindicated

For pregnant women who are asymptomatic and status unknown and at risk, we identified consensus that

  • A surgical mask or N-95 respirator should be worn during hospital appointments
  • Vaginal birth is not contraindicated
  • Epidural/spinal analgesia is not contraindicated
  • Delayed umbilical cord clamping is not contraindicated

For pregnant women who are asymptomatic AND not at risk due to close contact with known COVID-19 positive person, we identified consensus that

  • A surgical mask or N-95 respirator should be worn during hospital appointments
  • Partners of labouring women accompanying them during labour is not contraindicated
  • Delayed umbilical cord clamping is not contraindicated

We did not find consensus for any other recommendations for our key questions.

  • It is important to note that this work does not make recommendations.  Rather, it identifies, collates and summarises clinical practice guideline recommendations on key clinical questions available across a number of countries. We also explored the level of consensus in recommendations for each question across countries. 
  • No formal quality assessment of included guidelines was undertaken and we do not endorse recommendations from any country.
  • Recommendations from individual countries may differ from guidance by international organisations.  

You can access full results in several ways by watching the PowerPoint slide deck video or clicking on the relevant link below:

 

Other resources

Pregnancy Review of maternal health recommendations related to the COVID-19 pandemic

The Burnet Institute have conducted a rapid review of national and international guidance for managing women in pregnancy or giving birth during the COVID-19 pandemic.

Pregnancy and neonatal outcomes in women with confirmed COVID-19

Cochrane Gynaecology and Fertility  have created an Excel sheet that contains data extracted from all published reports on pregnancy and neonatal outcomes in women with confirmed COVID-19. They are updating the data as soon as new reports are published online (please note that this data table has not been peer reviewed). You can download it here.   Do YOU have unpublished data on pregnancy and neonatal outcomes in women with confirmed COVID-19? If so, please send it to Dr Madelon van Wely (m.vanwely@amsterdamumc.nl) - It is important that we have as much information as possible.

WHO are seeking standardized clinical data on all hospitalized patients to improve understanding of the natural history of disease, and disaggregated for children and pregnant women.   WHO have developed a pregnancy/postpartum module to be included in the current Case Report Forms (CRFs) recommended to report cases (https://isaric.tghn.org/novel-coronavirus/). This will allow WHO to get more information on pregnant and recently pregnant women and potential complications, as well as fetal/neonatal outcomes. To contribute to anonymized data to the WHO Global COVID-19 Clinical Data Platform; contact EDCARN@who.int  to get log-in credentials.  More information, including clinical characterization research protocols, Case Report Forms and updates on research are available here: https://isaric.tghn.org/.