COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics

 Staffing, Personnel, and Hospital Resources

• When can an obstetric care professional with SARS-CoV-2 infection or exposure return to work? When they return to work, what personal protective equipment (PPE) do they need to wear on a regular basis? REVISED

  Last updated January 14, 2022 at 10:06 a.m. EST.

  The Centers for Disease Control and Prevention (CDC) has developed guidance outlining work restrictions for health care personnel (HCP) with SARS-CoV-2 exposures based on the risk level of the exposure, the PPE used at the time of exposure, and the vaccination status of the individual. Furthermore, the CDC provides recommended work restrictions for HCP with SARS-CoV-2 infection and exposures based on a facility's level of need to mitigate HCP and staffing shortages. Clinicians are encouraged to review these work restrictions and recommendations from the CDC regularly, as they are updated frequently. Additionally, clinicians are encouraged to work with their facilities, as situations may vary based on local circumstances.

  After adhering to any applicable restrictions and returning to work, HCP should do the following:

  • Always wear a face mask for source control (to contain respiratory secretions) while in the health care facility until all symptoms are completely resolved or at baseline. After this time period, HCP should revert to their facility's policy regarding universal source control during the pandemic.
    • As with other respiratory illnesses, a residual nonproductive cough may persist for weeks after the illness has otherwise resolved. This is also the case for SARS-CoV-2 infection. Therefore, it is possible that an individual will meet the criteria for returning to work despite having lingering symptoms.
    • A face mask for source control does not replace the need to wear an N95 or higher-level respirator (or other recommended PPE) when indicated (read What personal protective equipment (PPE) should clinicians and patients wear for potential or confirmed COVID-19 cases?).
  • Self-monitor for symptoms and seek reevaluation from an occupational health specialist if respiratory symptoms recur or worsen.
• Q: What personal protective equipment (PPE) should health care professionals wear to reduce their risk of COVID-19 infection? REVISED

  Last update July 1, 2021 at 7:00 a.m. EST

  COVID-19 infection is highly contagious, and this must be taken into consideration when planning intrapartum care. Recommendations for personal protective equipment (PPE) from the Centers for Disease Control and Prevention (CDC) can be found on the CDC's website. CDC also provides strategies for how to optimize the supply of PPE.

  As vaccination rates increase, it is still critical to maintain general infection control strategies in health care settings. Regardless of vaccinations status, obstetric care clinicians should still wear adequate and appropriate PPE when caring for patients with suspected or confirmed COVID-19.

• Q: What is the best approach to cleaning surfaces and ultrasound equipment?

  Last updated November 4, 2020 at 1:49 p.m. EST.

  Clinicians should follow CDC guidance in regards to properly cleaning surfaces.

  AIUM has published guidelines for cleaning and preparing external- and internal-use ultrasound transducers and equipment that include specific recommendations during the COVID-19 pandemic. For external and interventional procedures, low-level disinfection is effective when used according to CDC guidelines. EPA-approved disinfectants for use against COVID-19 (SARS-CoV-2) can be found online. If low-level disinfectant agents are depleted, then soap and water should be used per CDC guidelines. If indicated but no transducer covers are available, medical gloves or other physical barriers should be used. Along with the ultrasound transducer, it is important to clean all ancillary equipment involved in the procedure. In addition to low-level disinfectant cleaning, a cover sheet may be used as a physical barrier between the keyboard/console and the operator. If possible, use a dedicated system (scanner and transducers) for COVID-19, positive or suspected, patients. In instances where a patient who is COVID-19 positive and requires an aerosolizing procedure, a transducer cover should be used and all equipment requires low-level disinfection both inside and outside of the exam room. In addition to following manufacturer usage guidelines, health care professionals should follow their health care facility’s infection control policies. 

General Considerations

• Q: Should oral SARS-CoV-2 protease inhibitor therapy be used as a treatment option for pregnant patients? (REVISED)

  Last updated January 10, 2022 at 12:44 p.m. EST.

  Recently, an oral severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) protease inhibitor, PAXLOVID (which includes nirmatrelvir, a SARS-CoV-2 main protease inhibitor, and ritonavir, an HIV-1 protease inhibitor and CYP3A inhibitor) became available only under emergency use authorization (EUA) (EUA, EUA Fact Sheet). It is recommended for the treatment of outpatients with mild to moderate COVID-19 infection with a positive result of a SARS-CoV-2 viral test and who are at high risk of clinical progression as defined by the EUA criteria. Pregnancy is included among the conditions that put individuals at high risk for clinical progression. This makes pregnant patients, including those with pregnancy as their only risk factor, eligible to receive outpatient oral SARS-CoV-2 protease inhibitor therapy, according to the EUA. Obstetric care clinicians may consider the use of the oral SARS-CoV-2 protease inhibitor for the treatment of non-hospitalized COVID-19 positive pregnant individuals with mild to moderate symptoms, particularly if one or more additional risk factors are present (eg body mass index >25, chronic kidney disease, diabetes mellitus, cardiovascular disease). Clinicians should weigh the available data against the individual risks of COVID-19 in pregnancy in each situation.

  There are no available human data on the use of nirmatrelvir during pregnancy to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. In an embryo-fetal development study with nirmatrelvir, reduced fetal body weights following oral administration of nirmatrelvir to pregnant rabbits were observed at systemic exposures approximately 10 times higher than exposure at the authorized human dose of PAXLOVID. Published observational studies on ritonavir use in pregnant women have not identified an increased risk of birth defects. Ritonavir has been used extensively during pregnancy in people living with HIV, which suggests that it has an acceptable safety profile during pregnancy. No other adverse developmental outcomes were observed in animal reproduction studies with nirmatrelvir or ritonavir at systemic exposures greater than or equal to 3 times higher than clinical exposure at the authorized human dose of PAXLOVID (EUA Fact Sheet). The short-term exposure to these medications must be balanced against the maternal and fetal risks associated with untreated COVID-19 in pregnancy.

  If utilizing protease inhibitor (PAXLOVID) treatment, this treatment should be initiated orally as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset. PAXLOVID should be administered orally with or without food. The recommended dosage is 300 mg of nirmatrelvir (two 150 mg tablets) with 100 mg of ritonavir (one 100 mg tablet), with all three tablets taken together twice daily for 5 days. 

  Obstetric care clinicians should be aware that the concomitant use of PAXLOVID and certain other drugs (including medications used in obstetric settings such as nifedipine, methylergonovine, fentanyl, midazolam, or betamethasone) may result in potentially significant drug interactions. Prescribing clinicians should consult the full prescribing information prior to and during treatment for potential drug interactions (EUA Fact Sheet).

  Lactation is not a contraindication for the use of this oral SARS-CoV-2 protease inhibitor (EUA Fact Sheet). Lactating individuals with one or more risk factors for severe COVID-19 illness may receive SARS-CoV-2 protease inhibitor for treatment. There are no available data on the presence of nirmatrelvir in human or animal milk, the effects on the breastfed infant, or the effects on milk production. A transient decrease in body weight was observed in the nursing offspring of rats administered nirmatrelvir. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for PAXLOVID and any potential adverse effects on the breastfed infant from PAXLOVID or from the underlying maternal condition (EUA Fact Sheet).

  Efforts should be made to ensure that communities most affected by SARS-CoV-2 have equitable access to these treatments.

• Q: What are the criteria to discontinue transmission-based precautions for previously COVID-19 positive patients? (REVISED)

  Last updated August 24, 2022 at 10:55 a.m. EST

  According to CDC's guidance, discontinuation of transmission-based precautions in the health care setting for an individual with confirmed COVID-19 should be made using a symptom-based strategy (CDC). The time period used depends on the patient's severity of illness and if they are severely immunocompromised. Meeting criteria for discontinuation of transmission-based precautions is not a prerequisite for discharge from a healthcare facility. Patients who are discharged home for required isolation or who are treated as outpatients with a diagnosis of COVID-19 should follow discontinuation of isolation precautions guidance from the CDC. Recommendations regarding discontinuation of transmission-based precautions may continue to evolve. ACOG encourages members and patients to visit CDC's website for up to date information and details.

  Detailed information on exposure, isolation, quarantine, and testing is available through the CDC. Individuals are encouraged to review this information regularly.

• Q: Does COVID-19 present an increased risk of severe morbidity and mortality for pregnant and recently pregnant individuals? REVISED

  Last updated February 17, 2022 at 9:16 a.m. EST

  Compared to Pregnant and Recently Pregnant Individuals Without COVID

  Available data suggest that, compared to pregnant individuals without SARS-CoV-2 infection,  SARS-CoV-2 infection during pregnancy (particularly moderate or severe infection) is associated with increased risk of a composite outcome of maternal mortality or serious morbidity from obstetric complications such as hypertensive disorders of pregnancy, postpartum hemorrhage, or infection other than SARS-CoV-2 (Metz 2022).

  Compared to Nonpregnant Individuals with COVID-19

  Available data suggest that symptomatic pregnant women with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers (Ellington MMWR 2020, Collin 2020, Delahoy MMWR 2020, Khan 2021). CDC includes pregnant and recently pregnant individuals in its “increased risk” category for severe COVID-19 illness. Although the absolute risk for severe COVID-19 is low, available data indicate an increased risk of ICU admission, need for mechanical ventilation and ventilatory support (ECMO), and death reported in pregnant women with symptomatic COVID-19 infection, when compared with symptomatic non-pregnant women (Zambrano MMWR 2020, Kahn 2021). Compared to asymptomatic pregnant patients, severe–critical COVID-19 illness has been associated with adverse perinatal outcomes such as increased risk of cesarean birth and hypertensive disorders of pregnancy, while mild-to-moderate illness has not been associated with adverse perinatal outcomes (Metz 2021). Some emerging data have suggested an association between COVID-19 infection and preeclampsia (Papageroghiou 2021, Conde-Agudelo 2021). However, COVID-19 can cause similar clinical findings to some forms of preeclampsia. As such, data regarding COVID-19 and preeclampsia are mixed and to date, there is not a clear relationship between COVID-19 infection and preeclampsia.

  While data indicate an increased risk of severe illness and maternal death, data also indicate that the majority of pregnant individuals diagnosed with COVID-19 experience relatively mild symptoms; however, symptoms lasting up to 8 weeks have been reported (Yee 2020).

  Special Populations

  Pregnant and recently pregnant patients with comorbidities such as obesity, diabetes, hypertension, and lung disease may be at an even higher risk of severe illness consistent with the general population with similar comorbidities (Ellington MMWR 2020, Panagiotakopoulos MMWR 2020, Knight 2020, Zambrano MMWR 2020, Galang 2021). Further, the risk of moderate-to-severe or critical illness during pregnancy appears to increase with increasing maternal age (Metz 2021, Galang 2021). Black and Hispanic individuals who are pregnant appear to have disproportionate SARS CoV-2 infection and death rates (Ellington MMWR 2020, Moore MMWR 2020, Zambrano MMWR 2020).

  Counseling and Prevention

  Clinicians should counsel pregnant individuals and those contemplating pregnancy about the potential risk of COVID-19, and measures to prevent infection with SARS-CoV-2 should be emphasized for these individuals and their families. Pregnant individuals are encouraged to take all available precautions to avoid exposure to COVID-19 and optimize health including:

  • Getting a COVID-19 vaccine during pregnancy or postpartum, if not already vaccinated
  • Follow routine hygiene practices including washing hands often
  • Continue following safety measures to prevent COVID-19 infection, especially if not fully vaccinated, including wearing a mask, maintaining physical distancing, and limiting contact with other individuals as much as practical

  The increased risk of severe illness for pregnant and recently pregnant people highlights the critical importance of vaccination for family members and clinicians caring for these individuals. ACOG recommends that pregnant and recently pregnant people receive a COVID-19 vaccine, if not already vaccinated, to protect themselves. Information on vaccination is available in the ACOG Practice Advisory “COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care.”

• Q: What is the effect of COVID-19 on fetal and neonatal outcomes? REVISED

  Last updated March 21, 2022, at 11:10 a.m. EST

  Although there are cases of reported vertical transmission of SARS-CoV-2, currently available data indicate that vertical transmission appears to be uncommon (Dumitriu 2020). Pregnant people with COVID-19 are at increased risk for preterm birth and some data suggest an increased risk for other adverse pregnancy complications and outcomes, such as preeclampsia, coagulopathy, and stillbirth, compared with pregnant people without COVID-19 (Allotey 2020, Jering 2021, Ko 2021, Villar 2021, DeSisto 2021). Data now indicate that neonates born to people with COVID-19 are also at increased risk for admission to the neonatal intensive care unit (Allotey 2020, Villar 2021). ACOG is aware of case series reporting uncommon but severe placentitis in pregnant individuals with SARS-CoV-2 (Fitzgerald 2022, Hecht 2020). However, these reports have several limitations, including lack of a control group and selection bias. More data regarding placentitis frequency in pregnant individuals with SARS-CoV-2 infection, timing of onset, and severity of SARS-CoV-2 infection are needed to confirm any association between SARS-CoV-2 and placentitis and to guide any potential changes in clinical management. Until then, see the “Do patients with suspected or confirmed COVID-19 need additional antenatal fetal surveillance?” FAQ. In addition to more data regarding placental function and pathology, more data are needed to understand the possible association between SARS-CoV-2 infection and delivery timing, and SARS-CoV-2 and neonatal outcomes.

  Population level changes in preterm birth and stillbirth rates have also been noted when comparing periods of COVID-19 lockdown to a time period prior to COVID. In Europe, decreases in rates of preterm delivery have been reported along with increased number of stillbirths, but initial evidence in the United States suggests preterm delivery and stillbirth rates are unchanged (Handley 2020, Hedermann 2020, Kahlil 2020, Yang 2022).

  ACOG continues to monitor the emerging literature on these topics.

  Clinicians should counsel pregnant individuals and those contemplating pregnancy about the potential risk of COVID-19, and measures to prevent infection with SARS-CoV-2 should be emphasized for those who are pregnant and their families. Pregnant individuals are encouraged to take all available precautions to avoid exposure to COVID-19 and optimize health including:

  • Getting a COVID-19 vaccine during pregnancy or postpartum, if not already vaccinated
  • Follow routine hygiene practices including washing hands often
  • Continue following safety measures to prevent COVID-19 infection, especially if not fully vaccinated, including wearing a mask, maintaining physical distancing, and limiting contact with other individuals as much as practical
• Q: Should pregnant patients wear a mask? REVISED

  Last updated October 12, 2022 at 3:36 p.m. EST.

  With regard to wearing a mask, pregnant patients should follow the same recommendations as the general population as outlined by the CDC. The CDC now provides recommendations for prevention strategies, including mask wearing, based on COVID-19 community levels (low, medium, and high). The COVID-19 community level is determined by a combination of three metrics: new COVID-19 cases, new COVID-19 hospital admissions in the past week, and the percentage of hospital beds occupied by COVID-19 patients. The use of these new COVID-19 community levels can help communities and individuals determine the appropriate prevention measures, including mask wearing, based on local context and unique needs.

  Pregnant individuals are at increased risk for severe disease; therefore, it is extremely important that pregnant individuals in high COVID-19 community level areas continue to use masks. Even in low COVID-19 community level areas, pregnant individuals may wish to continue wearing masks and should be supported if they decide to do so. There are currently no known risks related to mask use during pregnancy.

  Recently, the CDC revised its infection control guidelines and included updates to its recommendations for source control (mask wearing) in health care settings. When community transmission levels are not high, health care facilities could choose not to require universal masking (CDC). This change is due to the high level of vaccine- and infection-induced immunity and the availability of effective treatments and prevention tools. However, even in the setting of moderate or low COVID-19 community transmission levels, it may be prudent to continue to require masks in health care settings to mitigate the spread of respiratory infections such as COVID-19 and influenza, particularly during seasons when many viruses are co-circulating. Clinicians should refer to the guidance of their respective health care facilities regarding the use of masks for both clinicians and patients.

  While in the health care setting, patients should adhere to respiratory hygiene when required, cough etiquette, and hand hygiene, and follow triage procedures. Masks also should continue to be worn while utilizing public transportation, during travel, and while in travel hubs such as airports (CDC, IDSA). Patients who are sick with COVID-19 and their caregivers also should wear a mask or respirator.

  Emerging data demonstrate that while all masks and respirators provide some level of protection against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), properly fitting respirators provide the highest level of protection. It is most important for individuals to wear a well-fitting mask or respirator correctly so that it is comfortable and provides good protection (CDC). Importantly, masks with exhalation valves or vents should NOT be worn to help prevent the person wearing the mask from spreading COVID-19 to others (source control) (CDC).

  Clinicians and patients should be aware that CDC recommendations regarding mask wearing may change frequently and CDC and/or state officials may reinstate mask mandates, as needed.

• Q: Should routine screening testing continue to occur in labor and delivery units? REVISED

  Last updated January 10, 2023 at 4:46 p.m. EST.

  Pregnant individuals admitted for labor and delivery with suspected COVID-19 or who develop symptoms suggestive of COVID-19 during admission should be tested (CDC, AMA statement). Performance of SARS-CoV-2 viral testing upon admission to labor and delivery is at the discretion of the facility. For asymptomatic patients, the yield of screening testing for identifying infection is likely lower when performed on those in counties with lower levels of SARS-CoV-2 community transmission. However, these results might continue to be useful in some situations (e.g., when performing higher-risk procedures or for HCP caring for patients who are moderately to severely immunocompromised) to inform the type of infection control precautions used and prevent unprotected exposures.

  Regardless of vaccination status, individuals may decline testing for a variety of reasons including stigma, mistrust, and fear of possible mother–baby separation. Facilities that continue to practice routine screening testing in labor and delivery should have a plan for the care of individuals who decline COVID-19 testing.

• Q: How should thromboprophylaxis be managed for pregnant and postpartum patients with suspected or confirmed COVID-19 infection? REVISED

  Last updated July 1, 2021 at 7:22 a.m. EST

  Pregnancy is a hypercoagulable state, and women who are pregnant or in the postpartum period have a fourfold to fivefold increased risk of thromboembolism compared with nonpregnant women (Practice Bulletin 196, Thromboembolism in Pregnancy). Data indicate that COVID-19 infection may lead to increased coagulopathy. Although not yet known, it is possible that pregnancy and COVID-19 infection may be additive for risk of thrombosis. The National Institutes of Health COVID-19 Treatment Guidelines recommends that pregnant patients hospitalized for severe COVID-19 receive prophylactic dose anticoagulation unless contraindicated. 
  
  Additional resources:

  • American Society of Hematology. COVID-19 and VTE/Anticoagulation: Frequently Asked Questions
  • National Institutes of Health. COVID-19 Treatment Guidelines. Antithrombotic Therapy in Patients with COVID-19
  • COVID-19 resources on coagulation and anticoagulation (International Society on Thrombosis and Haemostasis)

  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists.)

• Q: Should monoclonal antibodies be used as a treatment option for pregnant patients? REVISED

  Last updated February 17, 2022 at 9:16 a.m. EST

  Various monoclonal antibody treatments are available only under emergency use authorization (EUA). They are recommended for the treatment of outpatients with mild to moderate COVID-19 infection who are at high risk of clinical progression as defined by the EUA criteria. Recently, the Omicron variant of SARS-CoV-2 has rapidly become the dominant COVID-19 viral strain worldwide. Most approved anti-SARS-CoV-2 monoclonal antibodies have a diminished potency or are ineffective against the Omicron variant.

  Pregnancy is included among the conditions that put individuals at high risk for clinical progression. This makes patients with pregnancy as their only risk factor eligible to receive outpatient monoclonal antibodies, according to the EUA (NIH). Obstetric care clinicians may consider the use of monoclonal antibodies for the treatment of non-hospitalized COVID-19 positive pregnant individuals with mild to moderate symptoms, particularly if one or more additional risk factors are present (eg BMI >25, chronic kidney disease, diabetes mellitus, cardiovascular disease).

  Post-exposure prophylaxis should be considered for inadequately vaccinated individuals who have been exposed to SARS-CoV-2 (NIH). These individuals include those who have had a recent exposure to an individual with SARS-CoV-2 for a cumulative total of 15 minutes or more over a 24-hour period or there is a recent occurrence of SARS-CoV-2 infection in other individuals in the same institutional setting AND are 1) not fully vaccinated or 2) fully vaccinated but may not mount an adequate immune response.

  Lactation is not a contraindication for the use of monoclonal antibodies. Lactating individuals with one or more risk factors for severe COVID-19 illness may receive monoclonal antibodies for treatment or post-exposure prophylaxis. There is no need to temporarily discontinue breastfeeding when receiving monoclonal antibodies.

  People who previously received monoclonal antibodies as part of COVID-19 treatment, post-exposure prophylaxis, or pre-exposure prophylaxis can be vaccinated at any time; COVID-19 vaccination no longer needs to be delayed following receipt of monoclonal antibodies.

  Due to current reduced effectiveness of some monoclonal antibodies against the Omicron variant, physicians should consult their facilities as to which monoclonal antibody therapies against SARS-CoV-2 infection are available for treatment options.

  A recent analysis of data from 41 health care systems found that White and non-Hispanic patients received monoclonal antibody treatment more often than Black, Asian, and Other race [including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and multiple or Other races] patients with positive SARS-CoV-2 test results (Wiltz 2022). As with other COVID-19 treatments, vaccines, and prevention practices, efforts (e.g., considering measures of social vulnerability in patient triage, engaging trusted messengers in outreach, and directly addressing structural barriers to access) should be made to ensure that communities most affected by SARS-CoV-2 have equitable access to these treatments.

Prenatal Care

• Q: Do patients with suspected or confirmed COVID-19 need additional antenatal fetal surveillance?

  Last updated November 4, 2020 at 1:54 p.m. EST.

  During acute illness, fetal management should be similar to that provided to any critically ill pregnant person. Continuous fetal monitoring in the setting of severe illness should be considered only after fetal viability, when delivery would not compromise maternal health or as another noninvasive measure of maternal status.

  Very little is known about the natural history of pregnancy after a patient recovers from COVID-19. In the setting of a mild infection, management similar to that for a patient recovering from influenza is reasonable. It should be emphasized that patients can decompensate after several days of apparently mild illness, and thus should be instructed to call or be seen for care if symptoms, particularly shortness of breath, worsen. Given how little is known about this infection, a detailed mid-trimester anatomy ultrasound examination may be considered following pre-pregnancy or first-trimester maternal infection. Interval growth assessments could be considered depending on the timing and severity of infection, with the timing and frequency informed by other maternal risk factors. Antenatal testing is reserved for routine obstetrical indications (SMFM Coronavirus COVID-19 and Pregnancy).

  ACOG will continue to carefully monitor the literature to provide our members with the best available and most current guidance. Should new literature indicate any need for additional antenatal fetal surveillance for pregnant patients with suspected or confirmed COVID-19, ACOG will update our recommendations accordingly.

• Q: Should pregnant women continue to receive maternal immunizations during the COVID-19 pandemic? REVISED

  Last updated May 26, 2021 at 2:09 p.m. EST.

  Yes. Maternal immunizations continue to be an essential component of prenatal care during the COVID-19 pandemic. Additionally, COVID-19 vaccines can be given with other routine maternal immunizations and there is no need to withhold routine maternal immunizations for any time period before or after receiving COVID-19 vaccination. Adhering to the recommended timing of maternal immunization as much as possible is encouraged to maximize maternal and fetal benefits. If a practice decides to modify or reduce the number of prenatal care visits, clinicians are encouraged to include recommended maternal immunizations (influenza and Tdap) during remaining in-person appointments, even if that means immunizations will be administered outside of the typically recommended weeks of gestation. Modified prenatal care schedules during COVID-19 may make it disproportionately more difficult for some to receive preventive care such as maternal immunizations. This reality underscores the importance of clinicians integrating social determinants of health screening into practice, and maximizing and facilitating referrals to social services (Committee Opinion 729).

  Importantly, there is no evidence that vaccination with either the influenza vaccine or Tdap vaccine increases a pregnant woman’s or fetus’ risk of infection with or complications from the virus that causes COVID-19.

  Similar to other infectious diseases, if a postpartum individual has suspected or confirmed COVID-19 and did not receive indicated immunizations prior to (e.g. MMR) or during (influenza & Tdap) pregnancy, those immunizations should be delayed until the patient has fully recovered from illness. 

• Q: Is there any benefit associated with the use of corticosteroid treatment for pregnant patients with moderate to severe COVID-19 illness?

  Last updated July 27, 2020 at 5:24 p.m. EST.

  A preliminary published analysis from a large, multicenter, randomized, open-label trial for hospitalized patients in the United Kingdom demonstrated that patients who were randomized to receive dexamethasone (6mg once daily; oral or IV) had a reduced rate of mortality compared to those who received standard of care (NEJM 2020). In the dexamethasone group, the incidence of death was lower than that in the standard care group among patients requiring mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving supplemental oxygen at enrollment (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.91 to 1.55).  Therefore, for the general population, the NIH now recommends using dexamethasone (at a dose of 6 mg per day for up to 10 days) in patients with COVID-19 who are mechanically ventilated and in patients with COVID-19 who require supplemental oxygen but who are not mechanically ventilated. The NIH recommends against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen. Although these recommendations are not specific to pregnant individuals, ACOG recommends that dexamethasone be used for pregnant women with COVID-19 who are receiving supplemental oxygen or are mechanically ventilated, and that dexamethasone should not be withheld for treatment of COVID-19 due to pregnancy status.  
  
  ACOG will continue to diligently monitor the literature on the use of corticosteroids for patients with suspected or confirmed COVID-19.

   

Postpartum Care

• Q: How should lactating individuals be counseled about special considerations for infant feeding with breastmilk in the setting of suspected or confirmed maternal COVID-19 infection? REVISED

  Last updated February 11, 2022 at 3:15 p.m. EST.

  Breastmilk provides protection against many illnesses and there are few contraindications to breastfeeding (Committee Opinion 756, CDC's Pregnancy and Breastfeeding). Current evidence suggests that breastmilk is not a source of COVID-19 infection (Walker 2020, CDC). A recent cohort of 110 lactating women found no SARS-CoV-2 infectious material in breastmilk samples (Krogstad 2022). Therefore, suspected or confirmed maternal COVID-19 is not considered a contraindication to infant feeding with breastmilk.

  Individuals with suspected or confirmed COVID-19 can transmit the virus through respiratory droplets while in close contact with the infant, including while breastfeeding. Therefore, obstetrician-gynecologists and other maternal care practitioners should counsel patients with suspected or confirmed COVID-19 who intend to infant feed with breastmilk on how to minimize the risk of transmission, including:

  • Breastmilk expression with a manual or electric breast pump. This includes the importance of proper hand hygiene before touching any pump or bottle parts and following recommendations for proper pump cleaning after each use. If possible, individuals should consider having someone who does not have suspected or confirmed COVID-19 infection and is not sick feed the expressed breastmilk to the infant. Additionally, individuals should be counseled on whether the birthing facility is able to provide a dedicated breast pump.
  • Safety measures if breastfeeding. A mother with suspected or confirmed COVID-19 who wishes to breastfeed her infant directly should take all possible precautions to avoid spreading the virus to her infant, including hand hygiene and wearing a mask or cloth face covering, if possible, while breastfeeding. 

  Even in the setting of the COVID-19 pandemic, obstetrician–gynecologists and other maternal care practitioners should support each patient's informed decision about whether to initiate or continue breastfeeding, recognizing that the patient is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal (Committee Opinion 756).

  A child being breastfed by someone with suspected or confirmed COVID-19 should be considered as a close contact of a person with COVID-19, and should be quarantined for the duration of the lactating parent’s recommended period of isolation and during their own quarantine thereafter (CDC).

  ACOG will continue to review emerging literature on this topic.

• Q: How should a mother-infant dyad be located in the hospital when the mother has suspected or confirmed SARS-CoV-2 infection?

  Last updated August 11, 2020 at 1:31 p.m. EST.

  Early and close contact between the mother and neonate has many well-established benefits including increased success with breastfeeding, facilitation of mother-infant bonding, and promotion of family-centered care. Given the available evidence on this topic, mother-infant dyads where the mother has suspected or confirmed SARS-CoV-2 infection should ideally room-in according to usual facility policy. Although data is still emerging and long-term effects are not yet fully understood, data suggests that there is no difference in risk of SARS-CoV-2 infection to the neonate whether a neonate is cared for in a separate room or remains in the mother’s room (CDC).
  
  Importantly, any determination of whether to keep individuals with known or suspected SARS-CoV-2 infection and their infants together or separate after birth should include a process of shared decision-making with the patient, their family, and the clinical team. This issue should be raised during prenatal care and continue through the intrapartum period. Healthcare providers should respect maternal autonomy in the medical decision-making process. Decision-making around rooming-in or separation should be free of any coercion, and facilities should implement policies that protect an individual’s informed decision.
  
  For mothers with suspected or confirmed COVID-19, rooming-in should be combined with safety measures to minimize the risk of transmission, including:

  • Mother using a mask or cloth face covering and practicing hand hygiene prior to and during all contact with the neonate. Masks or cloth face coverings should not be placed on neonates or children younger than 2 years of age.
  • Engineering controls such as using physical barriers (eg, placing the neonate in a temperature-controlled isolette) and keeping the neonate 6 feet or more away from the mother as often as possible.
  • If it is possible to have a non-health care professional caregiver provide care for the neonate while in the hospital, it should be an individual who is not at increased risk for severe illness and uses appropriate infection prevention precautions (e.g., wearing a mask, practicing hand hygiene).

  While enabling rooming-in is a key practice to encourage and support breastfeeding, there may be circumstances (related to COVID-19 or otherwise) where temporary separation is appropriate for the well-being of the mother and neonate. Decisions about temporary separation should be made in accordance with the mother’s wishes. 

  Considerations for counseling patients considering temporary separation include:

  • Mothers with suspected or confirmed SARS-CoV-2 infection do not pose a potential risk of virus transmission to their neonates if they have met the criteria for discontinuing isolation and precautions:
    • At least 10 days have passed since their symptoms first appeared (up to 20 days if they have more severe to critical illness or are severely immunocompromised), and
    • At least 24 hours have passed since their last fever without the use of antipyretics, and
    • Their other symptoms have improved.
  • Mothers who have not met these criteria may choose to temporarily separate from their neonates in an effort to reduce the risk of virus transmission. However, if after discharge they will not be able to maintain separation from their neonate until they meet the criteria, it is unclear whether temporary separation while in the hospital would ultimately prevent SARS-CoV-2 transmission to the neonate, given the potential for exposure from the mother after discharge.
  • Separation may be necessary for mothers who are too ill to care for their infants or who need higher levels of care.
  • Separation may be necessary for neonates at higher risk for severe illness (e.g., preterm infants, infants with underlying medical conditions, infants needing higher levels of care).
  • Consideration for separation as an approach to reduce the risk of transmission from a mother with suspected or confirmed SARS-CoV-2 to her neonate is not necessary if the neonate tests positive for SARS-CoV-2.

  If temporary separation is undertaken, mothers who intend to breastfeed should be supported and encouraged to express their breastmilk to establish and maintain the milk supply. If possible, a dedicated breast pump should be provided (see How should women be counseled about special considerations for infant feeding with breastmilk in the setting of suspected or confirmed maternal COVID-19 infection?). 

   

Special Populations

• Q: Are there special considerations for incarcerated pregnant people? REVISED

  Last updated July 1, 2021 at 7:16 a.m. EST.

  Prisons, jails, and detention facilities are high-risk environments for COVID-19 transmission, and ACOG has provided recommendations for addressing the needs of pregnant and postpartum individuals who are incarcerated during the pandemic. For pregnant people who must remain in custody, prisons, jails, and detention facilities should implement measures for social distancing, hygiene, screening, testing, medical care including COVID-19 vaccination, safe housing arrangements, and other interventions as outlined by the CDC’s Interim Guidance on Management of COVID-19 in Correctional and Detention Facilities and as recommended by guidance from the National Commission on Correctional Health Care. As institutions of incarceration adapt operations in response to the pandemic, they must ensure that pregnant people continue to have access to comprehensive health care, including prenatal care, abortion care, postpartum care and breastmilk expression, and timely assessment of pregnancy-related or COVID-19 symptoms, in accordance with ACOG guidance.

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