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Coronavirus disease 2019 (COVID-19) pandemic and pregnancy

Published:March 23, 2020DOI:https://doi.org/10.1016/j.ajog.2020.03.021
      The current coronavirus disease 2019 (COVID-19) pneumonia pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is spreading globally at an accelerated rate, with a basic reproduction number (R0) of 2–2.5, indicating that 2–3 persons will be infected from an index patient. A serious public health emergency, it is particularly deadly in vulnerable populations and communities in which healthcare providers are insufficiently prepared to manage the infection. As of March 16, 2020, there are more than 180,000 confirmed cases of COVID-19 worldwide, with more than 7000 related deaths. The SARS-CoV-2 virus has been isolated from asymptomatic individuals, and affected patients continue to be infectious 2 weeks after cessation of symptoms. The substantial morbidity and socioeconomic impact have necessitated drastic measures across all continents, including nationwide lockdowns and border closures.
      Pregnant women and their fetuses represent a high-risk population during infectious disease outbreaks. To date, the outcomes of 55 pregnant women infected with COVID-19 and 46 neonates have been reported in the literature, with no definite evidence of vertical transmission. Physiological and mechanical changes in pregnancy increase susceptibility to infections in general, particularly when the cardiorespiratory system is affected, and encourage rapid progression to respiratory failure in the gravida. Furthermore, the pregnancy bias toward T-helper 2 (Th2) system dominance, which protects the fetus, leaves the mother vulnerable to viral infections, which are more effectively contained by the Th1 system. These unique challenges mandate an integrated approach to pregnancies affected by SARS-CoV-2.
      Here we present a review of COVID-19 in pregnancy, bringing together the various factors integral to the understanding of pathophysiology and susceptibility, diagnostic challenges with real-time reverse transcription polymerase chain reaction (RT-PCR) assays, therapeutic controversies, intrauterine transmission, and maternal−fetal complications. We discuss the latest options in antiviral therapy and vaccine development, including the novel use of chloroquine in the management of COVID-19. Fetal surveillance, in view of the predisposition to growth restriction and special considerations during labor and delivery, is addressed. In addition, we focus on keeping frontline obstetric care providers safe while continuing to provide essential services. Our clinical service model is built around the principles of workplace segregation, responsible social distancing, containment of cross-infection to healthcare providers, judicious use of personal protective equipment, and telemedicine. Our aim is to share a framework that can be adopted by tertiary maternity units managing pregnant women in the flux of a pandemic while maintaining the safety of the patient and healthcare provider at its core.

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        American Journal of Obstetrics & GynecologyVol. 224Issue 1
        • Preview
          We thank Carbillon and coworkers for their perspectives on the optimal dose of chloroquine in pregnancy. The novel use of chloroquine phosphate and hydroxychloroquine in the management of coronavirus disease 2019 (COVID-19) is an area of evolving research. Our rationale for high-dose chloroquine was based, at the time, on expert consensus from the Chinese Ministry of Health and data from the interim analysis of a study by the Health Commission of Guangdong province, China, which supported the use of a twice-daily 500-mg regimen in the clinical management of COVID-19.
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        American Journal of Obstetrics & GynecologyVol. 224Issue 1
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          Recent publications on the novel coronavirus disease 2019 (COVID-19) regarding the high-risk populations have focused on the elderly, those with cardiovascular disease, diabetes, and, women during pregnancy. An important article by Dashraath et al1 that was recently published in the American Journal of Obstetrics & Gynecology provided a thorough summary of the factors that need to be considered for pregnancy, maternal health, and postpartum care during the time of COVID-19, and guidelines on how these factors should be addressed and monitored.
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      • Hydroxychloroquine at usual doses as an option for coronavirus disease 2019 treatment
        American Journal of Obstetrics & GynecologyVol. 224Issue 1
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          We read with great interest the article by Dashraath et al.1 During pregnancy, the onset of severe acute respiratory syndrome (SARS) can jeopardize both mother and fetus and may cause extreme prematurity, as in previous coronavirus outbreaks.
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