Pregnancy and Covid 19

The COVID19 virus also affects pregnant women. While the vast majority of infected patients have few symptoms, about 10% of them may have a pneumonia that is important to diagnose and treat. Initial data from the literature suggest management similar to that of the general population. There is a greater risk of premature delivery requiring the administration of corticosteroids for fetal lung maturation in the event of imminent delivery. The route of delivery should be guided by obstetric history even though a large proportion of caesarean sections are included in the published series. Loco-regional anaesthesia is allowed. To date, only a few cases of mother-foetal transmission have been described, rather related to per- or postpartum transmission. The rate of perinatal morbidity and mortality is very low. Only one maternal death has been described. Breastfeeding is allowed with protective measures (hand disinfection, mask for the delivery). In conclusion, all the current studies suggest that pregnant women infected with COVID-19 and their newborn babies have a good prognosis of evolution, but it will be necessary to wait for large multicentric and well-documented series to confirm these data.


Introduction
A new strain of coronavirus called SARS (Severe Acute Respiratory Syndrome) -CoV-2 or COVID-19 was isolated from humans in late 2019 in China. She is currently responsible for a pandemic recognized by WHO as a public health emergency. If 75% are not very symptomatic (flu-like syndrome, myalgia, headache, cough, nasal congestion), the remaining 25% may present with moderate to severe respiratory distress having taken hospital care and sometimes respiratory assistance. Incubation is on average 5 days (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14) and contagiousness is greater than that of seasonal influenza. The population particularly at risk of complications concerns elderly, immunocompromised patients or those who carry co-morbid factors such as obesity, cardiovascular disease, diabetes or cancer [1,2]. The pregnant woman could theoretically be part of these risk groups by immunosuppression induced by pregnancy as well as other physiological changes such as elevation of the diaphragm, increased oxygen consumption, edema. respiratory mucous membranes which make it more vulnerable to hypoxia [3]. complaints were fever (86%) and cough (60%). In biology, lymphopenia was present in 80% of cases. All patients received a low-dose chest CT scan (between 0.01 and 0.66 mGy) with a lead abdominal apron that showed images of frosted glass opacities, with peripheral distribution that appear to be pathognomonic for COVID pneumonia. All patients were put on oxygen and none used mechanical ventilation. They did not receive antiviral treatment or hydroxy-chloroquine but only an antibiotic carrier to avoid bacterial superinfection [7]. The latest meta-analysis published by Zaigham and Andersson analysed 108 pregnancies with proven COVID-19 infection, the majority of which were in the Chinese population [8]. In 80% of cases, the infection occurred in the third trimester, with 68% having fever, 34% coughing, 59% lymphocytopenia and 70% elevated CRP. A caesarean section was performed in 91% of cases. With regard to foetal and neonatal morbidity, there was 1 case of foetal death in utero, 1 neonatal death at 34 weeks [9]. In this meta-analysis, it is noted that there were two newborns tested positive for COVID-19 (PCR) and carrying IgM antibodies to COVID, suggesting a possible infection in utero [10]. In the USA, a first series of 43 cases of infected pregnant women reported a rate of 67.4% of symptomatic patients (86% moderate, 9.3% severe and only 4.7% critical) Among the 32.6% of asymptomatic patients detected by universal testing, 70% later presented symptoms [11].

Covid-19 and Pregnancy: What we Know from the Chinese Experience
Finally, a first case of maternal-fetal mortality linked to COVID-19 was reported by Karami et al in Iran in a young 27-yearold patient in the third trimester with severe pneumonia leading to intubation and lethal multisystemic decompensation [12].

Proposed Care For Pregnant Women Infected With Covid-19
Several consensus articles on the management of pregnant women with a suspected or confirmed diagnosis of VIDOC- 19 [14]. Indeed, the risk of teratogenicity of these antivirals is very low [18]. c.

The Decision to Give Birth
This should not be taken before term except in the event of a deterioration in maternal health or foetal distress. There appears to be no benefit in recommending a Caesarean section unless the pneumonia is severe and uncontrolled. In the Chinese studies, they were mostly carried out because of a deterioration in foetal cardiac monitoring [13,15].

The Delivery
It should ideally take place in a room with negative pressure.
Staff should be limited to what is strictly necessary and should be equipped with appropriate protective clothing. The route of delivery is related to obstetric conditions, but the risk of Caesarean section must be anticipated to enable the teams to take adequate protective measures in case of emergency [19]. Caesarean section, it is recommended that thromboprophylaxis be maintained for 6 weeks postpartum [20]. The use of prostaglandins as a utero tonic should be discussed with internists in view of their broncho constrictor effect in cases of severe pneumonia

Fetal Complications
To date, no studies have reported cases of fetal malformation or miscarriage associated with COVID-19, but caution should be exercised due to the lack of information on the evolution of infected pregnancies in the first and second trimesters, and one case of in utero mortality in a context of severe maternal respiratory distress and ECMO [5]. There is an increased incidence of premature deliveries, some of which are spontaneous as a result of infection and pyrexia, but others are elective as a result of fetal distress or deterioration in maternal status [4][5][6][7]. Given that the pandemic occurred only 4 months ago, there is also a lack of information on the long-term consequences of the inflammation produced after the acute phase of infection on the fetus and placenta. For this reason, there is a need for closer ultrasound follow-up in patients infected during pregnancy, even if they were moderately infected, and for long-term studies of the fate of the children.

Neonatal Complications
The risk of maternal-fetal vertical transmission appears to be very low and even non-existent in the small series published to date (4,5,7,8) but the whole paragraph will be discussed in another article in this special issue.

Conclusions
Pregnant women are by definition at greater risk of developing a lung infection mainly due to physiological changes in lung function [3]. All the studies based on small series and meta-analyses show that pregnant women infected with COVID-19 and their newborns have a rather good prognosis both in terms of morbidity and mortality.