Joint statement on elective surgeries.
- 1.Because of the life-threatening, morbidity-related, and/or time-sensitive nature of conditions requiring intervention, most fetal procedures are not “elective.” These include, but are not limited to:
- a.Fetal blood transfusions
- b.Interventions for complicated monochorionic multiple gestations, including fetoscopic placental laser surgery or selective reduction
- c.Shunting procedures for conditions with substantial fetal compromise, such as hydropic hydrothoraces or cystic lung lesions
- d.Open fetal surgical procedures that are not experimental or under research protocols, such as, but not limited to, open maternal-fetal surgery for fetal myelomeningocele repair and ex utero intrapartum therapy for anticipated neonatal airway compromise
- 2.The above recommendations should be applied regardless of a patient’s COVID-19 status. The decision to intervene may be influenced by the maternal condition. Maternal health always takes priority over fetal status.
- 3.The limited evidence to date regarding the risk of vertical transmission of SARS-CoV-2 infection through fetal intervention should be included in the informed consent discussion before such procedures.
- 4.Fetal therapists should strive to avoid transplacental passage of their needle or (in particular) fetoscope or shunt trocar. Avoiding transplacental procedures becomes especially pertinent when there is a potential risk of maternal-fetal viral transmission. An exception might be fetal transfusion into an anterior placental cord insertion, if the fetal intrahepatic vein was inaccessible. Open fetal surgical procedures may carry a higher risk of such transmission.
- 5.General anesthesia is a high-risk procedure for viral transmission. The anesthetic risks, and that of horizontal transmission of SARS-CoV-2 infection to HCPs, should be discussed among the patient and her HCPs.5Procedures that violate the aerodigestive mucosa and/or result in body fluid aerosolization are associated with SARS-CoV-2 transmission.Society for Obstetric Anesthesia and Perinatology
Interim considerations for obstetric anesthesia care related to COVID19.5Most fetal procedures can be performed under conscious sedation and local anesthesia, which reduces maternal risk and SARS-CoV-2 exposure risk to HCPs.Society for Obstetric Anesthesia and Perinatology
Interim considerations for obstetric anesthesia care related to COVID19.
- 6.Appropriate personal protective equipment (PPE) must be worn for all encounters with patients diagnosed as having COVID-19 or patients classified as person under investigation (PUI). This applies for any potentially aerosolizing procedures, including endotracheal intubation for general anesthesia or neonatal intubation.2,5Society for Obstetric Anesthesia and Perinatology
Interim considerations for obstetric anesthesia care related to COVID19.
- 7.Equipment, including ultrasound machines, must be cleansed thoroughly between patients, especially if the patient is positive for COVID-19, following stringent cleansing protocols.6ISUOG
ISUOG safety committee position statement on use of personal protective equipment and hazard mitigation in relation to SARS-CoV-2 for practitioners undertaking obstetric and gynecological ultrasound.
- 8.Only essential HCPs should participate in procedures on patients with positive COVID-19 or patients classified as PUI.
- 9.All nonessential personnel should limit direct patient contact. Whenever possible, patient encounters, for example, subspecialty consultation or result follow-up, should be conducted virtually.3Dedicated fetal therapy nursing and care coordination remain critical components of the fetal care team.
- 10.The potential exacerbation of known or unrecognized maternal SARS-CoV-2 infection that could result in increased fetal or maternal morbidity or mortality with any intervention must be considered. Where appropriate, infectious disease consultation should be entertained.
- 11.Decisions should be made based on local medical, operational, and organizational considerations, influenced by local COVID-19 burden. Parents should be informed that treatment availability may change at short notice, because of local healthcare adjustments as they adapt to evolving pandemic trends.
- 12.Preoperative SARS-CoV-2 testing for patients undergoing fetal interventions should follow local policies and guidelines, according to access to testing and result response time. For patients who receive positive test results for SARS-CoV-2 or are symptomatic, procedures should be delayed for 14 days or until patients meet local criteria for disease resolution. If the fetal condition requires immediate intervention, and if the mother is stable, the procedure should be performed using appropriate PPE.
- 13.Practice guidelines for procedures during the COVID-19 pandemic are continually evolving as information emerges. The North American Fetal Therapy Network will closely monitor emerging evidence and will update their guidelines accordingly (https://www.naftnet.org).
- 14.All interventional research protocols should be suspended during the pandemic. No clinical benefit for the fetus or newborn is lost, because the experimental outcomes are unknown. However, we encourage recruitment of pregnant women and neonates with SARS-CoV-2 infection into registries that may clarify the risk of vertical transmission (Table).
- 15.Fetal therapy centers must carefully consider whether they can still offer certain, highly resource-intensive, fetal procedures if their staffing becomes depleted, because of either illness or deployment to other intensive care areas. In regions with multiple fetal therapy programs, this may be a time for collaboration, volume reduction, and/or referral of certain cases.
- 16.Patients traveling between states, provinces, or countries should be counseled that, by such travel, they may expose themselves to a higher risk of SARS-CoV-2 infection. They may also become obliged to remain at their destined center for an unpredictable time period. After some procedures, patients may return earlier than usual to their referring HCPs for ongoing monitoring and care. Fetal therapy centers should remain engaged with the referring HCP by phone or telemedicine. If travel restrictions are implemented, patients who need to travel to a distant fetal therapy center may require supporting documentation. Some centers may decline to accept patients with a positive result for COVID-19 testing or come from regions with a high infection prevalence.
|Registry||Website||Patient recruitment from||Inclusion criteria/objectives|
|PRIORITY||https://priority.ucsf.edu/||United States only||Pregnant or recently pregnant women, either under investigation for SARS-CoV-2 infection or with confirmed COVID-19|
|COVI-Preg||https://www.covi-preg.ch||International||Any pregnant patient suspected of SARS-CoV-2 infection|
|PAN COVID||https://pan-covid.org||International||Any woman in pregnancy or postnatal period and/or their neonate with suspected or confirmed SARS-CoV-2 infection|
MFMU sites only
|All women with SARS-CoV-2 infection in pregnancy or within 6 wk after delivery, at any MFMU hospital site|
|CHOPAN||https://www.covid19chopan.health||Australia, New Zealand, and Pacific region||All women diagnosed as having COVID-19 in pregnancy. Neonatal outcomes to 1 mo of age|
|UKOSS||https://www.npeu.ox.ac.uk/ukoss/current-surveillance/covid-19-in-pregnancy||United Kingdom only||Incidence of hospitalization with SARS-CoV-2 infection in pregnancy, assessing maternal and infant outcomes|
|ROI COVID-19||https://www.ucc.ie/en/npec/roicovid-19study/||Ireland only||All pregnant women and newborns aged <29 d who have been tested for SARS-CoV-2|
|NethOSS||https://www.nvog.nl/actueel/registratie-van-covid-19-positieve-zwangeren-in-nethoss/||Netherlands only||Pregnant women with SARS-CoV-2 infection|
|CAN COVID-Preg||https://ridprogram.med.ubc.ca/cancovid-preg/||Canada only||Pregnant women with COVID-19 infection and their newborns up to 6 weeks|
- SAR-CoV2 (COVID-19) infection: is fetal surgery in times of national disasters reasonable?.Prenat Diagn. 2020; ([Epub ahead of print])
- MFM guidance for COVID-19.Am J Obstet Gynecol MFM. 2020; ([Epub ahead of print])
- Virtually perfect? Telemedicine for Covid-19.N Engl J Med. 2020; 382: 1679-1681
- Joint statement on elective surgeries.(Available at:)https://s3.amazonaws.com/cdn.smfm.org/media/2266/Joint_Statement_on_Elective_Surgeries_031620.pdf(Accessed April 2020)Date: 2020
- Interim considerations for obstetric anesthesia care related to COVID19.(Available at:)https://soap.org/wpcontent/uploads/2020/03/SOAP_COVID19_Obstetric_Anesthesia_Care_032320.pdf(Accessed April 2020)Date: 2020
- ISUOG safety committee position statement on use of personal protective equipment and hazard mitigation in relation to SARS-CoV-2 for practitioners undertaking obstetric and gynecological ultrasound.(Available at:)https://www.isuog.org/resource/isuog-safety-committee-position-statement-on-use-of-personal-protective-equipment-and-hazard-mitigation-in-relation-to-sars-cov-2-for-practitioners-undertaking-obstetric-and-gynecological-ultrasound.html(Accessed April 2020)Date: 2020
The authors report no conflict of interest. The North American Fetal Therapy Network is supported through funding by the Eunice Kennedy Shriver National Institute of Child Health and Human Development ( 5R131HD059293-05 ).
This communication has been published in the middle of the coronavirus disease 2019 pandemic and is available via expedited publication to assist patients and healthcare providers.