Covid19 and pregnancy

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Covid19 and pregnancy

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Covid19 and pregnancy: As per ICMR Guidelines Pregnant women do not appear more likely to contract the infection than the general population. However, pregnancy itself alters the body’s immune system and response to viral infections in general, which can occasionally be related to more severe symptoms and this will be the same for COVID-19. – PowerPoint PPT presentation

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Title: Covid19 and pregnancy


1
COVID19 AND PREGNANCY
Dr. Shivani Sachdev Gour M.D. DNB, M.R.C.O.G.
(UK) Dr. Nupur Garg M.S. (Obs Gyn) F.R.M
2
KEYPOINTS
  • Introduction
  • Virology and Epidemiology Clinical Manifestation
  • Prevention
  • Course in pregnancy
  • Approach to diagnosis
  • Prenatal care
  • Management of Labour and Delivery PP care
  • Abortion/ MTP/ Ectopic Pregnancy
  • HCW Prophylaxis

3
Introduction
  • Coronaviruses are family of enveloped,
    single-stranded RNA viruses mainly cause mild
    symptoms like common cold
  • At the end of 2019, a novel coronavirus was
    identified in a worker in Wuhan Sea food market
    in the Hubei Province of China who had pneumonia.
  • It was observed that this strain exhibited
    stronger virulence and quickly passed
  • from human to human
  • In Jan 2020, the WHO designated the disease as
    public health emergency
  • It designated this virus as 2019 Novel Corona
    virus later it was renamed as
  • severe acute respiratory syndrome coronavirus 2
  • (SARS-CoV-2) previously, it was referred to as
    2019-nCoV.

4
Corona Virus- Notorious past History
  • 2 epidemics in the past belong to ß corona virus
    .Mild illness belonged to a,?,?
  • 2002 Severe acute respiratory syndrome
    Coronavirus (SARS-CoV)
  • 2012 Middle East respiratory syndrome
    Coronavirus (MERS-CoV)
  • 2019 named SARS-CoV 2 as on genome sequencing
    shared 79.5 identity to SARS-CoV. use
    angiotensin-converting enzyme 2 (ACE2), the same
    receptor as SARS-CoV , to infect humans (ZhouP
    Nature 2020)
  • Designated severe acute respiratory syndrome
    coronavirus 2 (SARS-CoV-2)
  • Earlier referred to as 2019-nCoV.
  • Viral mutations is key for explaining potential
    disease relapses
  • In February 2020, the WHO designated the disease
    COVID-19, which stands for coronavirus disease
    2019

4
5
Marco CascellaFeatures evaluation and
treatment of corona virus 2020
5
6
Routes Of Transmission
  • Droplets do not linger in air
  • Do not travel more than 2 meters
  • Also detected in blood and stools
  • According to a joint WHO-China report,
    fecal-oral transmission did not appear to be a
    significant factor in the spread of infection

6
7
  • LUNGS
  • KIDNEY
  • GI TRACT
  • VASCULAR ENDOTHELIUM

2 modes of entry into respiratory epithelium
binding to ACE 2 receptors or direct fusion
Causes cell injury and release of execessive
inflammatory cytokines a s apart of normal
immune defence mechanism .This Cytokine Storm
or sustained inflammatory response leads to
extensive tissue damage, exudate production and
mucus plugging of bronchioles leading to V/Q
mismatch and pneumonia .IL-6 main cytokine
causing the storm Yan Rong Gua Military Medical
Reasearch7 2020
8
Marco CascellaFeatures evaluation and treatment
of corona virus 2020
8
9
SYMPTOMS
Marco CascellaFeatures evaluation and treatment
of corona virus 2020
9
10
Disease Severity Category
  • Mild (no or mild pneumonia),
  • Severe (eg, with dyspnea, hypoxia, or
  • gt50 percent lung involvement on imaging within
    24 to 48 hours)
  • Critical (eg, with respiratory failure, shock,
    or multiorgan dysfunction)
  • Wu Z JAMA 2020, Yang X Lancet Respir
  • Med 2020

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Onder G JAMA 2020,Verity R Lancet Infec Dis 2020
11
12
  • Risk of Infection in Pregnant
  • Women
  • Pregnancy does not increase the risk to contract
    the infection
  • than the general population.
  • But Pregnancy alters the bodys immune system and
    can cause
  • more severe symptoms with COVID-19.
  • This is particularly true towards the end of
    pregnancy, after 28 weeks .

13
ICMR Guidelines
Effect of COVID-19 on Pregnancy
  • Pregnant women do not appear more likely to
    contract the infection than the general
    population. However, pregnancy itself alters the
    bodys immune system and response to viral
    infections in general, which can occasionally be
    related to more severe symptoms and this will be
    the same for COVID- 19.
  • Reported cases of COVID-19 pneumonia in pregnancy
    are milder and with good
  • recovery.
  • Pregnant women with heart disease are at highest
    risk (congenital or acquired).

14
ICMR Guidelines
Effect of COVID-19 on Pregnancy
  • In other types of coronavirus infection (SARS,
    MERS), the risks to the mother appear to
    increase in particular during the last trimester
    of pregnancy.
  • There are case reports of preterm birth in women
    with COVID-19 but it is unclear whether the
    preterm birth was always iatrogenic, or whether
    some were spontaneous.
  • The coronavirus epidemic increases the risk of
    perinatal anxiety and depression, as well as
    domestic violence. It is critically important
    that support for women and families is
    strengthened as far as possible that women are
    asked about mental health at every contact

15
  • A small study of nine pregnant women in Wuhan,
    China, with confirmed COVID-19 found no evidence
    of the virus in their breast milk, cord blood or
    amniotic fluid.

16
Concluded that the subjects didnt experience
more severe pneumonia than non-pregnant patients
17
  • A small retrospective study published in The
    Lancet reviewed obstetric and neonatal outcomes
    of seven pregnant women at a hospital in Wuhan
    who had contracted COVID-19 in their third
    trimesters. The outcomes for all seven women
    were good none were admitted into intensive
    care and all were discharged from the hospital.

18
Cochrane Database on COVID19 (coronavirus
disease) - Pregnancy
  • According to WHO, pregnant women
  • do not appear to be at higher risk of
  • severe disease.
  • Furthermore, WHO reports that currently there is
    no known difference between the clinical
    manifestations of COVID-19 in pregnant and non-
    pregnant women of reproductive age

19
  • A (WHO) report concluded that out of 147
    pregnant women diagnosed with COVID-19, 8 had
    what the WHO classified as severe disease and
    1 were critical.
  • It was determined that they werent more likely
    than non- pregnant people to develop
    life-threatening illness

20
  • A study of 43 pregnancy women in New York with
    confirmed COVID-19 published in the American
    Journal of Obstetrics Gynecology in April
    found that
  • unlike SARS and H1N1, pregnant women do not seem
    to experience more severe illness from the
    coronavirus compared to the general population.

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  • A study published as a letter in The New England
    Journal of Medicine looked at testing data from
    pregnant women who delivered between March 22
    and April 4 at New YorkPresbyterian Allen
    Hospital and Columbia University Irving Medical
    Center in New York City.
  • Out of 215 patients, 88 percent of the women who
    tested
  • positive for COVID-19 did not show any symptoms

23
ACOG is advising caution based on the impact of
other respiratory illnesses (including
influenza/ SARS outbreak of 20022003), stating
that pregnant women should be considered an
at-risk population for COVID-19.
24
  • Precautions for all pregnant
    women
  • Social distancing-at least 1 meter
  • Avoid unnecessary visits outside home
  • Avoid contact with people suffering from viral
    illnesses
  • Practise Hand hygiene, Respiratory hygiene,
  • Avoiding touching the face
  • Work from home

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ROUTINE ANC CARE IN TIMES OF COVID
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Routine ANC Visits Basic Principles
  • Routine Antenatal visits to be kept minimal
  • Consultation on phone or video conferencing
  • Come alone or keep the number of people
    accompanying to one
  • Follow hand hygiene,wear masks and
    gloves,frequent hand sanitisation pre and post
    visit

27
MFM GUIDANCE FOR COVID 19
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Modified ANC routine In Current scenario
  • 75 gm 2hr GTT instead of 50 gmGCT
  • Cell-free DNA screening (at gt10 weeks) rather
    than the combined test (ie,
  • nuchal translucency on ultrasound and serum
    analytes)
  • Fetal kick counts hand outs to be given
  • Teleconsultation
  • Home BP monitoring
  • Screen for symptoms on phone . Patients who are
    symptomatic, suspected or COVID19 positive
    within the last 2 weeks.Phone Triage.
  • MFM GUIDANCE FOR
  • COVID 19

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Suggested timing/frequency of growth
ultrasounds
in pregnancy
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  • Summary of common indications for antenatal
    surveillance and adjusted NST recommendations in
    setting of COVID19 pandemic
  • ACOG MFM Guidance
  • 2020

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Indications for testing COVID 19 in
pregnancy-ICMR
  • 1. A pregnant woman who has acute respiratory
    illness with one of the
  • following criteria
  • a history of travel abroad in the last 14 days (6
    March 2020 onwards).
  • is a close contact of a laboratory proven
    positive patient or
  • she is a healthcare worker herself or
  • hospitalized with features of severe acute
    respiratory illness.
  • 2. A pregnant woman who is presently asymptomatic
    should be tested between 5 and 14 days of coming
    into direct and high risk contact of an
    individual who has been tested positive for the
    infection.

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  • Rapid Tests Guidelines
  • In hotpots/cluster as per MOHFW and in large
  • migration gatherings/evacuees centers
  • All symptomatic ILI(fever,cough,sore throat,runny
    nose)
  • a.Within 7 days-rRT-PCR b.After 7 days Antibody
    test(If
  • Negative,confirmed by rRT-PCR)

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Test Method
  • CDC recommends collection of a nasopharyngeal
    swab specimen
  • Detected by reverse-transcription polymerase
    chain reaction (RT-PCR)
  • Centers authorized by the government of India and
    state governments
  • false negative rate of 10-30 even with two
    serial swabs
  • In the near future, testing may be conducted by
    Nucleic Acid Ampli cation Test (NAAT) or by
    serological testing.
  • Serology faster and cheaper stay positive even
    after 3 weeks of infection

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Course of COVID 19 In Pregnancy
  • Most women have mild or moderate cold/flu like
    symptoms.
  • Other reported cases of COVID-19 pneumonia in
    pregnancy are milder and with good recovery
  • Women with severe diseases are those who have
    associated comorbidities like DM,HT,
    BMIgt40,respiratory disease or of advanced age
  • Pregnancy and Perinatal Outcomes of Women With
    Coronavirus Disease
  • (COVID-19) Pneumonia A Preliminary Analysis.Liu
    D, AJR Am J Roentgenol. 2020

37
Course of COVID 19 In Pregnancy
  • At present there is one published case of a woman
    with severe COVID- 19 admitted at 34 weeks, in
    the ICU with multiple organ dysfunction and
    acute respiratory distress syndrome, requiring
    extracorporeal membrane oxygenation
  • Data from Australia have identified that there
    are significant increases in
  • critical illness in later pregnancy, compared
    with early pregnancy
  • Liu Y, . Clinical manifestations and outcome of
    SARS-CoV-2 infection
  • during pregnancy. Journal of Infection 2020

38
Pregnancy complications due to COVID
  • Meta analysis by Mascio D,Am J Obstet Gynecol
    MFM. 2020 41 covid positive pregnant women were
    studied

Baby
  • Maternal
  • preterm birth lt37 weeks (41.1 ),
  • Stillbirth (2.4 )
  • Admission to a NICU (10 )
  • Neonatal death (2.4 )
  • PPROM (18.8 ),
  • preeclampsia (13.6 ),
  • cesarean delivery (91.1 ),
  • data reflect small numbers, related to severe
    maternal illness, women mostly intubated,may not
    directly due to fetal/neonatal infection with the
  • coronavirus

39
Effect on Fetus
  • Very recent evidence, suggests that the virus may
    be transmitted vertically( Dong L JAMA 2020) 3
    out of 33 neonates born to COVID positive
    mothers tested positive for corona virus
  • Chen et al. found no evidence of COVID-19 in the
    amniotic fluid or cord blood of 6 infants of
    infected women(Lancet 2020)

40
Effect on Fetus
  • Currently, there are inadequate data on COVID-19
    and
  • risk of miscarriage or congenital anomalies or
    fetal growth restriction.
  • Data from the SARS epidemic are reassuring,
    suggesting no increased risk of fetal loss or
    congenital anomalies associated with infection
    early in pregnancy
  • Shek CC, Pediatrics 2003 Oct

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Management of COVID 19 Positive
  • As per guideline by Indian Government,COVID 19
    positive patients Based on the symptoms patient
    are divided into 3 groups mild, moderate and
    severe.
  • Mild cases are shifted to government designated
    COVID CARE CENTER
  • Moderate cases are shfited to Dedicated COVID
    Health Center
  • Severe cases are shifted to Dedicated COVID
    Hospital

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  • ANC Care in COVID POSITIVE
  • ASYMPTOMATIC PATIENT
  • Routine appointments, scans / tests

  • should be delayed until after the recovery
  • If it is deemed that obstetric care cannot be
    delayed until after the period of isolation,
    infection prevention and control measures should
    be arranged locally to facilitate care preferably
    at the end of the working day
  • If ultrasound equipment is used, this should be
    decontaminated
  • after use in line with national guidance

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  • Management of COVID Gravid
    not in Labour
  • Symptomatic
  • Medical Supportive therapy rest, oxygen
    supplementation, fluid management and
    nutritional care as needed. Maternal oxygen
    saturation (SaO2) should be maintained at 95
    percent during pregnancy,
  • Fetal Survellience a Bluetooth-enabled external
    fetal monitor can transmit the fetal heart rate
    tracing to the obstetric
  • provider. (ACOG) MONICA NOVII WIRELESS PATCH
    SYSTEM.
  • Frequency as per gestation age and patient profile

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  • Fever Paracetamol is the preferred drug
  • Secondary bacterial infection pregnancy safe
    antibiotics

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Use of medications to manage pregnancy
complications in covid positive
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SPECIFIC MEDICATIONS
  • Hydroxychloroquine in a dose of 600 mg (200 mg
    thrice a day with meals) and Azithromycin (500
    mg once a day) for 10 days has been shown to
    give virological cure on day 6 of treatment in
    100 of treated patients in one study( JHMI
    Clinical Guidance for Available Pharmacologic
    Therapies for COVID-19)
  • Alternative dosage regimens for
    hydroxychloroquine are to give 400 mg
  • twice a day on day 1 and then 400 mg once a day
    for the next four days
  • Antiviral lopinavir-ritonavir (400/100 mg) twice
    daily for 14 days no difference in time to
    clinical improvement or mortality
  • was seen ( Cao B 2020)

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  • Side effects QTc prolongation, in particular, as
  • well as cardiomyopathy and retinal toxicity)
  • Published clinical data on either of these
  • agents are limited.

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Post recovery Follow Up
  • Scheduled ANC care that falls within the
    isolation period should be
  • rearranged for post-isolation.
  • If patient required hospitalisation for severe
    illness , ultrasound for fetal growth
    surveillance is recommended 14 days after
    resolution of acute illness.
  • No evidence yet that (FGR) is a risk of COVID-19
  • Two-thirds of pregnancies with SARS were affected
    by FGR and a placental abruption occurred in a
    MERS case,(Wong SF Am J Obstet Gynecol 2004

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  • LABOUR MANAGEMENT
  • MFM LABOUR AND DELIVERY GUIDANCE FOR
  • COVID 19 AJOG 2020

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MFM LABOUR AND DELIVERY GUIDANCE FOR COVID 19
  • Timing of Delivery
  • In most women with non severe illness delivery
    not indicated
  • In critically ill intubated pregnant woman gt32
    weeks,delivery may relieve the extra metabolic
    and pulmonary load.
  • Possible benefits of this need to be weighed
    against the possible risks of worsening the
    systemic status with a surgical intervention.

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  • Mode Of Delivery
  • Mode of birth should not be influenced by the
  • presence of COVID-19,
  • unless the womans respiratory condition demands
    urgent delivery.

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Labour Triage
  • A protocol should be in place in every maternity
    unit to receive pregnant women in labour or
    suspected labour with confirmed or suspected
    COVID-19 infection.
  • The woman should call in advance to alert the
    maternity unit about her arrival whenever this is
    possible

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Precaution for transmission prevention
  • Designate rooms, or section of floor to be used
    for suspected/confirmed COVID-19 positive
    patients
  • Respiratory precautions
  • Room type Negative pressure room is not required
  • PPE should be used
  • Minimize change in providers.
  • Designate one team for COVID-19 patients.

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  • Precaution for transmission prevention
  • Birth attendants should be limited to one named
  • contact
  • Separate delivery room and operation theatres
  • Neonatal resuscitation corners located at least 2
    m
  • away from the delivery table
  • Patient should wear mask during labour and
    delivery

58
Attendence in Labour
  • AT first arrivalfull maternal and fetal
    assessment should be done
  • Assessment of the severity of COVID-19 symptoms
    by a multidisciplinary team(Pulmonary,critical
    care team)
  • Maternal observations including temperature,
    respiratory rate and oxygen saturations
  • CTG-fetal surveillance
  • Inform anesthetist and Neonatologist

59
Care in Labour
  • Maternal vital monitoring as standard with the
    addition of hourly oxygen saturations.
  • Oxygen therapy for maternal reasons only to keep
    oxygen saturation gt 94
  • RCOG recommends continous electronic fetal
    monitoring
  • Oxytocin augmentation is recommended to shorten
    time to delivery
  • Early intervention with oxytocin and amniotomy
    for slow and dysfunctional
  • labour

60
Care in Labour
  • An individualised decision to shorten the second
    stage of labour with elective instrumental birth
    in a symptomatic woman who is becoming exhausted
    or hypoxic
  • In case of deterioration in the womans symptoms
    assesment of risks and benefits of continuing
    the labour versus proceeding to emergency
    caesarean birth if this is likely to assist
    efforts to resuscitate the woman

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Labour management
  • All care should be taken to reduce need for blood
    transfusion
  • In addition to standard oxytocin, consideration
    should be made for prophylactic tranexamic acid
    and misoprostol (400 mcg buccally)
  • avoiding delayed cord clamping. RCOG recommends
    delayed clamping
  • Cord blood banking can be done(ACOG)(risk of
    COVID-19 transmission by blood products has not
    been documented and is unclear at present)

62
Anesthesia Consideration
  • Early epidural to minimize need for general
    anesthesia in the event of emergent cesarean
    section
  • COVID-19 is not a contraindication to neuraxial
    anesthesia
  • Iv analgesia should be avoided
  • General anesthesia is considered an aerosolizing
    procedure, should be avoided,if not then special
    personal protective equipment should be worn.

63
Infant evaluation CDC recommendations
  • Mothers with suspected COVID-19 and unknown test
    results (either pending or not tested) infants
    born to such women are not COVID- 19 suspects
  • Mothers with known COVID-19 infants are COVID-19
    suspects, and they should be tested,
  • isolated from other healthy infants cared for
    according to infection
  • control precautions for patients with confirmed
  • or suspected COVID-19

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  • Neonatal care of COVID positive patients
  • No evidence of COVID-19 transmission through
    breastmilk
  • However, given risk of neonatal morbidity from
    transmission through maternal exposure, CDC
    recommend separation of mother and neonate after
    discussion with mother
  • Separation not required if infant tests positive
  • RCOG and FOGSI recommends breast feeding with
    discussion of risk
  • factors with mother

65
Breastfeeding considerations
  • Breast milk provision (via pumping) is
    encouraged.
  • The CDC recommends that during temporary
    separation, women who intend to breastfeed
    should be encouraged to express their breast
    milk to establish and maintain milk supply.
  • Before expressing breast milk, women should
    practice appropriate hand/skin hygiene washing
    not just hands but also breast prior to pumping.

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  • Period of separation- AAP
  • until patient is afebrile for 72 hours without
    use
  • of antipyretics and
  • her respiratory symptoms are improved and
  • at least two consecutive SARS-CoV-2
    nasopharyngeal swab tests collected 24 hours
    apart are negative.

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PRECAUTIONS WHILE BREAST FEEDING
  • Wash hands before touching the baby, breast pump
    or
  • bottles.
  • Avoid coughing or sneezing on the baby while
    feeding.
  • Consider wearing a face mask, if available, while
    feeding
  • or caring for the baby.
  • Where a breast pump is used, follow
    recommendations for pump cleaning after each
    use.
  • Considering asking someone who is well to
  • feed the baby

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Postnatal care for COVID postive
  • Continued medical evaluation for respiratory
    status and symptoms and standard practices of
    routine postnatal care
  • Hygiene related to the puerperium and hand
    hygiene
  • Advice on management of engorged breasts when
    feeding has not been established and measures to
    enhance breastfeeding after the isolation period
    is completed.
  • Healthy, nutritious diet to recover from the
    infection and build
  • immunity

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Post partum care in Non Covid Patients IN
Current Scenario
  • Expedited Discharge Planning
  • All vaginal deliveries should have a goal of
    discharge on postpartum day 1, or even same day
    if possible for selected women.
  • All cesarean deliveries should have a goal of
    discharge on postoperative day 2, with
    consideration of postpartum day 1 discharge if
    meeting milestones.
  • Discuss anticipated maternal discharge with
    pediatrics/neonatology to determine timing of
    infant discharge.
  • Home care with supplies for blood pressure follow
    up will be critical to
  • expediting discharge of patients with a
    hypertensive disorder.

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  • Investigational approaches in
    treatment
  • Redesmivir nucleotide analogue that has activity
    against (SARS-CoV-2) in vitro.I.V agent
    systematic evaluation of the clinical impact of
    remdesivir on COVID-19 has not yet been
    published.
  • IL-6 pathway inhibitors no published clinical
    data supporting its use
  • Convalescent plasma

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  • Convalescent plasma
  • A case series described administration of plasma
    from donors who had completely recovered from
    COVID-19 to five patients with severe COVID-19
    on mechanical ventilation and persistently high
    viral titers despite investigational antiviral
    treatment .
  • The patients had decreased nasopharyngeal viral
    load, decreased disease severity score, and
    improved oxygenation by 12 days after
    transfusion, but these findings do not establish
    a causal effect.
  • Finding appropriate donors and establishing
    testing to confirm neutralizing activity of
    plasma may be logistical challenges.
  • Shen C JAMA 2020

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MTP/ Abortion care services RCOG
  • 1.4 Priority
  • Abortion care is an essential part of health
    care for women services must be maintained
    even where non-urgent or elective services are
    suspended.

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MTP/ Abortion care services RCOG
  • Abortion Attention

is time-sensitive. should be paid to
  • providing care as early as possible given
    gestational limits.
  • Organise access to abortion care
  • so that delays are minimised

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MTP/ Abortion care services RCOG
Suspected/ Confirmed COVID 19 If the woman
requires face-to-face assessment but the
pregnancy is likely to be under 20 weeks
gestation, care should be booked after at least
7 days since the illness started (unless she
continues to be unwell, excluding a persistent
cough).
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MTP/ Abortion care services RCOG
Suspected/ Confirmed COVID 19 If the woman is
suitable for an early medical abortion at home,
she should be advised to take this approach if
she has no or mild symptoms (persistent cough is
acceptable), and before the pregnancy reaches 10
weeks gestation
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MTP/ Abortion care services RCOG
  • Suspected/ Confirmed COVID 19
  • If the abortion cannot be safely deferred and
    face-to-face contact is necessary, request the
    woman attend at a specific time (typically end
    of clinic, in a location that is equipped to
    manage COVID-19 patients) so correct IPC
    (infection prevention and control) measures can
    be put in place. The woman should be given a
    surgical face mask to wear and asked to wash her
    hands on arrival.

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MTP/ Abortion care services RCOG
Suspected/ Confirmed COVID 19 If surgical
abortion is performed Perform vacuum aspiration u
nder LA or IV sedation where feasible to avoid
need for GA Consider whether Spinal Anesthesia or
iv sedation would be more appropriate than an
anaesthetic requiring ventilation.
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MTP/ Abortion care services RCOG
  • Suspected/ Confirmed COVID 19
  • Consider checking full blood count, clotting and
    blood group if unwell.
  • Ensure that best practice is followed to reduce
    risk of transmission of infection (e.g. limit
    number of people in theatre, use PPE and
    decontaminate area after procedure as
    recommended by PHE).

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MTP/ Abortion care services RCOG
  • Self-isolation due to contact with suspected
    COVID-19 same practices as described for
    suspected cases to be followed

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MTP/ Abortion care services RCOG
  • Given that it is especially important to reduce
    contact during the COVID-19 pandemic, providing
    a second dose of 400mcg misoprostol for women
    to use 34 hours after the first if they have
    completed the abortion would seem prudent.

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MTP/ Abortion care services RCOG
  • There is evidence that NSAIDs (e.g. ibuprofen
    400800 mg) are effective for abortion-related
    pain, but also evidence that paracetamol is not.
  • Use paracetamol in preference to ibuprofen for
    symptoms of confirmed/suspected COVID-19 but
    ibuprofen can continue to be used in other
    circumstances

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MTP In Indian Context
  • MTP Medication schedule H medication and cannot
    be prescribed online or on Telemedicine
  • Follow all general principles of practice as per
    MTP Act
  • Assessment of patient and filling of all consent
    forms is essential

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MTP In Indian Context
Follow Additional Local Government Guidelines
for COVID19 as appropriate for example in Noida
it is now mandatory to test for SARSCov2 prior
to any operative procedure.
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MTP In Indian Context
  • In Delhi at the hospital entrance a complete
    evaluation for any influenza like illness/
    travel history / contact with suspected/
    confirmed COVID19 case /hotspot area residence
    etc is taken and then the woman is referred to
    general OPD or a separate COVID care centre
    (test not done routinely for all operative
    procedures)

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Prefer Medical management If not possible
avoilaparoscopy
ECTOPIC PREGNANCY Mx in COVID 19 PANDEMIC
  • proceed with minilap
  • Concerns re Methotrexate as it Is a
    immunosuppresant. Is self isolation required?
  • No because it is approx two one off doses in
    women who have healthy Immune systems
  • Rare cases WBC count can fall so Follow up is
    must

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HCW PROPHYLAXIS
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