key: cord-0812103-wum2s6my
authors: Govind, A.; Essien, S.; Kartikeyan, A.; Fakokunde, A.; Janga, D.; Yoong, W.; Nakhosteen, A.
title: Re: Novel Coronavirus COVID-19 in late pregnancy: outcomes of first nine cases in an inner city London hospital
date: 2020-05-07
journal: Eur J Obstet Gynecol Reprod Biol
DOI: 10.1016/j.ejogrb.2020.05.004
sha: 13acba5c07595b6d9a8cabbe72d7e67bca3b4b30
doc_id: 812103
cord_uid: wum2s6my

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one of the nine babies was subsequently confirmed as COVID-19 positive (patient 1) based on nasopharyngeal RT-PCR.

We would like to focus on the first two mothers who were delivered by emergency CS due to inability to maintain oxygen saturation and to highlight the accompanying lymphopenia that were previously described in the cases reported by Sutton 1 and Zheng 2 .

J o u r n a l P r e -p r o o f Patient 1: A 33 year old woman with diet controlled gestational diabetes mellitus was admitted at 39 weeks gestation with flu-like symptoms and productive cough. A provisional diagnosis of pneumonia was made but she developed chest pain and became tachypnoeic.

Chest Xray revealed right basal consolidation and lymphopenia was noted (0.92x10 9 /l; normal: 1.2-3.6). Maternal nasopharygeal swabs were positive for SARS-CoV-2 RT-PCR and she underwent an emergency CS for sudden deterioration of respiratory function, requiring 15l/min of oxygen to maintain saturation of >95%. A live infant 4.165kgs was delivered with Apgar scores of 5 1 minute and 9 5 minutes and was immediately separated from the mother.

Following delivery, the patient continued to desaturate (80-85%) on 100% of oxygen and was transferred to a tertiary centre for extracorporeal membrane oxygenation (ECMO). The baby, subsequently confirmed as COVID-19 positive, developed pyrexia and exhibited signs of pneumonia on the sixth day but settled with benzylpenicillin and gentamycin.

A 29 year old lady was admitted at 27 weeks gestation with myalgia, cough, pyrexia >38.4 o C and dyspnoea. SARS-CoV-2 was diagnosed on basis of nasopharyngeal RT-PCR and chest Xray showed basal consolidation (figure 1). She was commenced on intravenous clarithromycin and cefuroxime but became tachypnoeic and was unable to maintain oxygen saturation. Lymphopenia (1.05x10 9 /l; normal: 1.2-3.6) was noted and an emergency CS was performed for deteriorating maternal respiratory function. She required mechanical ventilation for four days post-delivery before being "stepped down". The baby weighing 1.2kgs with Apgars of 2 1 minute and 6 5 minutes and required intubation because of prematurity. The baby was negative for nasopharyngeal, amniotic fluid and placental swabs RT-PCR for SARS-CoV-2 and was weaned off ventilation after 10 days. Table 1 shows that maternal symptoms can be variable and of interest is that cough (8/9) and anosmia (7/9) appear to be the commonest presentations in this small series. We had initially followed advice from Chinese literature which recommended isolation of the infected woman and her baby for 14 days 2 . However, given the limited data and considering the potential detrimental effects on feeding and bonding, the Royal Colleges of Midwifery and Obstetricians and Gynaecologists have now jointly issued a guideline 3 that COVID-19

women and their healthy babies should be kept together in the postpartum period.

Similarly, breast milk of affected mothers 4 has tested negative for COVID-19 and current evidence suggest that breast feeding is not contraindicated 3 .

The most recent systemic review of six studies involving 48 delivered women indicates low likelihood of vertical transmission 5 , although transplacental maternal-fetal transmission have been reported 1,2 including in our first case (where mother and baby were immediately separated and membranes had remained intact until CS). We can postulate that there may be a relationship between vertical transmission with maternal viral load as this was our most respiratory-compromised patient.

The same systemic review 5 noted that 96% of COVID-19 women were delivered by CS; however, we suspect that these were likely to be elective procedures for obstetric indications, like the last four women in our series, where COVID-19 had been detected several weeks prior to delivery in relatively stable patients.

We end this letter by reminding clinicians that many pregnant women with COVID-19 present with mild or even no symptoms. In the United Kingdom, we currently do not have the capacity or funds to screen all pregnant women as recommended by Sutton et al 1 but any recent onset of cough and anosmia warrants a high level of suspicion for screening. J o u r n a l P r e -p r o o f

Universal Screening for SARS-CoV-2 in Women Admitted for Delivery

Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr

Information for healthcare professionals

Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records

COVID19 during pregnancy: a systematic review of reported cases

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.