| | |

Received: 25 February 2020    Revised: 15 March 2020    Accepted: 18 March 2020    First published online: 1 April 2020

DOI: 10.1002/ijgo.13146

SPECIAL ARTICLE
Obstetrics

Expert consensus for managing pregnant women and

neonates born to mothers with suspected or confirmed novel
coronavirus (COVID-­19) infection

Dunjin Chen1*‡ | Huixia Yang2*‡ | Yun Cao3 | Weiwei Cheng4 | Tao Duan5 | 

Cuifang Fan6 | Shangrong Fan7 | Ling Feng8 | Yuanmei Gao9 | Fang He1 | Jing He10 | 
Yali Hu11 | Yi Jiang12 | Yimin Li13 | Jiafu Li14 | Xiaotian Li15 | Xuelan Li16 | 
Kangguang Lin17 | Caixia Liu18 | Juntao Liu19 | Xinghui Liu20 | Xingfei Pan21 | 
Qiumei Pang22 | Meihua Pu23 | Hongbo Qi24 | Chunyan Shi2 | Yu Sun2 | 
Jingxia Sun25 | Xietong Wang26 | Yichun Wang9 | Zilian Wang27 | Zhijian
Wang28 | Chen Wang2 | Suqiu Wu29 | Hong Xin30 | Jianying Yan31 | 
Yangyu Zhao32 | Jun Zheng33 | Yihua Zhou34 | Li Zou35 | Yingchun Zeng1 | 
Yuanzhen Zhang14 | Xiaoming Guan36

1
Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou City, Guangdong Province, China
2
Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
3
Department of Neonatology, Children's Hospital Affiliated of Fudan University, Shanghai, China
4
Department of Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
5
Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Shanghai, China
6
Department of Obstetrics and Gynecology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
7
Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China
8
Department of Perinatal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
9
Department of Critical Care Unit, the Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, China
10
Department of Obstetrics and Gynecology, Women's Hospital, Zhejiang University School of Medicine Hangzhou, Hangzhou, Zhejiang Province, China
11
Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, JiangSu Province,
China
12
Department of Pediatrics, Peking University First Hospital, Beijing, China
13
Department of Critical Care Unit, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, China
14
Department of Obstetrics and Gynecology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
15
Department of Obstetrics, Obstetrics and Gynecology, Hospital of Fudan University, Shanghai, China
16
Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi Province, China
17
Department of Affective Disorder, Brain Hospital Affiliated of Guangzhou Medical University, Guangzhou, Guangdong Province, China
18
Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
19
Department of Obstetrics and Gynecology, Chinese Academy of Medical Sciences & Peking Union Medical college Hospital, Beijing, China
20
Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, China
21
Department of Infectious Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, China
22
Department of Obstetrics and Gynecology, You'an Hospital, Capital Medical University, Beijing, China
23
Department of Pediatrics, Peking University Third Hospital, Beijing, China
24
Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
25
Department of Obstetrics and Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin, Helongjiang Province, China
26
Department of Obstetrics and Gynecology, Provincial Hospital Affiliated to Shandong University, Shandong Province, China

130  |  ©
wileyonlinelibrary.com/journal/ijgo
2020 International Federation of Int J Gynecol Obstet 2020; 149: 130–136
Gynecology and Obstetrics
Chen ET AL. |
      131

27
Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
28
Department of Gynecology and Obstetrics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
29
School of Health Education of Wuhan University, Wuhan, Hubei Province, China
30
Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Hebei Medical University, Hebei Province, China
31
Department of Obstetrics, Fujian Provincial Maternity and Children Hospital, Fuzhou, Fujian Province, China
32
Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
33
Department of Neonatology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
34
Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
35
Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
36
Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA

*Correspondence
Dunjin Chen, Department of Obstetrics and Abstract
Gynecology, The Third Affiliated Hospital of Objective: To provide clinical management guidelines for novel coronavirus (COVID-­19)
Guangzhou Medical University, Guangzhou
City, Guangdong Province, China. in pregnancy.
Email: [email protected] Methods: On February 5, 2020, a multidisciplinary teleconference comprising Chinese
Huixia Yang, Department of Obstetrics physicians and researchers was held and medical management strategies of COVID-­19
and Gynecology, Peking University First infection in pregnancy were discussed.
Hospital, Beijing, China.
Email: [email protected] Results: Ten key recommendations were provided for the management of COVID-­19

‡
infections in pregnancy.
These authors contributed equally.
Conclusion: Currently, there is no clear evidence regarding optimal delivery timing, the
[correction added on 25 April 2020, after
first online publication: the author name
safety of vaginal delivery, or whether cesarean delivery prevents vertical transmission at
has been corrected to Chen Wang] the time of delivery; therefore, route of delivery and delivery timing should be individu-
alized based on obstetrical indications and maternal–fetal status.

KEYWORDS
COVID-19; Expert consensus; Management guidelines; Neonates; Pregnant women

1 |  INTRODUCTION Chinese health officials continue to regularly update diagnosis

and treatment protocols and educate and update the public and
In late December 2019, multiple unexplained pneumonia cases front-­line healthcare providers.7 China developed the 5th edition of
appeared in Wuhan City, Hubei Province, China. On January 12, 2020, the National Health and Medical Commission Diagnostic Standard
WHO officially named this virus “2019 New Coronavirus (2019-­ with suspected or probable COVID-­19 infection in response to this
1
nCoV)”, now named COVID-­19. As of 10:00am CET on February 24, recent epidemic.8 On February 5, 2020, a multidisciplinary tele-
2020, WHO recorded a total of 79 331 confirmed cases globally: conference comprising maternal–fetal medicine and other experts
China had 77 262 confirmed cases and outside of China there were in or from China and the USA was held to discuss recommenda-
2069 cases (www.who.int). Confirmed cases of COVID-­19 infection tions specific to the management of pregnant patients. From this
were also found in Southeast Asia, Europe, North America, and else- meeting come the recommendations discussed below (Fig. 1). These
where, attracting worldwide attention. recommendations are likely to evolve as the course of this novel
Other coronaviruses, such as severe acute respiratory syndrome disease unfolds.
coronavirus (SARS-­CoV) and Middle East respiratory syndrome coro-
navirus (MERS-­CoV) have caused more than 10 000 infected patients
worldwide. The mortality rate of MERS-­CoV infection approaches 2 | ISOLATION AND SCREENING
37%.2–5 The mortality rate of SARS-­CoV infection is 10% in the gen-
eral population and as high as 25% in pregnant women.6 China has Women with symptoms suggestive of COVID-­19 should be immedi-
adopted infection control measures to isolate exposed people and ately isolated in a single room for screening, and movement of the
suspected cases in accordance with international standards. patient throughout the facility should be limited. Confirmed cases
 |
132       Chen ET AL.

Pregnant women and newborns with COVID-19 symptoms should go to designated clinicsic

Suspected COVID-19 infection

Two consecutive pathogenic tests Recommend isolation or isolation with

with negative results negative pressure room; complete etiological Etiology test with positive result
(sampling time at least 1 day apart) examination of the case

Excluded COVID-19 infection Confirmed COVID-19 infection

Critical patient Recommend negative pressure

Termination of isolation; transferred to ICU isolation or isolation ward for
Routine antenatal examination at negative pressure routine antenatal examination
obstetric clinics isolation ward and childbirth

Multidisciplinary team discuss timing

of termination of pregnancy, delivery
methods, anesthesia methods

Newborns should be isolated for 14 days

and closely monitored for COVID-19
Recovery from COVID-19 infection; breastfeeding is not
recommended during isolation

F I G U R E   1   Flowchart of consultation process for pregnant women with suspected COVID-­19 infection.

should be treated in a negative pressure room or isolation ward. 1. Even while screening, provide supportive care: ensure adequate
Women with signs of critical illness should be immediately trans- rest and sleep; ensure enough caloric intake; provide supple-
ferred to an intensive or critical care unit with negative pressure or mental oxygen or respiratory support as needed; and maintain
equivalent.8 Hospitals should establish a dedicated negative pressure fluid and electrolyte balance.
operating room for pregnant women who must deliver with con- 2. Initiate broad-spectrum antimicrobial therapy to cover community-
firmed COVID-­19 infection, and a dedicated neonatal negative pres- acquired pneumonia while initiating the diagnostic work-up.
sure isolation room for newborns should be established. Ideally, these 3. In an effort to reduce a rising number of deaths due to severe
rooms will be close to one another, to limit traffic and movement of COVID-19 disease, Chinese health officials have begun to rec-
persons under investigation (PUI) or women and infants with known ommend starting antiretroviral agents even though there is little
infection. Visitation may also need to be limited, as close familial empirical data supporting their efficacy. These may include:
contacts may still be within the window in which they are infectious (a) Alpha-interferon inhalation (5 million U each time for adults,
but asymptomatic. add 2  mL of sterile water for injection, twice per day). The
use of this drug in early pregnancy has the risk of hindering
fetal growth and development and fully informed oral consent
3 |  INITIAL TREATMENT AND should be obtained.9
DIAGNOSTIC CONFIRMATION (b) Lopinavir/ritonavir (200 mg/50 mg, per capsule) two capsules,
twice per day. Lopinavir/ritonavir has been used in the treat-
It is critical to distinguish COVID-­19 from the following infectious and ment of pregnancy with HIV and the data show no ­significant
non-­infectious diseases, and to continue to pay close attention to and teratogenicity10; the concentration in breast milk is very low,
appropriately treat patients with other infections (Table  1). There is and no lopinavir/ritonavir is detected in ­breastfed infants.11–14
currently no clear evidence of definitive treatment for COVID-­19, and The use of antiretroviral medications has not been recommended
the mainstay of treatment is supportive care. worldwide, and providers should consider the most up-­to-­date
Chen ET AL. |
      133

T A B L E   1   Differential diagnosis of acute severe respiratory distress. women be admitted and isolated in an intensive care or critical care
unit with negative pressure rooms. Pregnant women may have better
Category Examples
uteroplacental oxygenation while lying in a lateral-­decubitus position,
Viral pneumonia Influenza, parainfluenza, adenovirus, respiratory
regardless of the mother's respiratory status.
syncytial virus, SARS, MERS
Bacterial Mycobacterium pneumococcus, Streptococcus
1. Antimicrobial coverage: for pregnant women with suspected or
pneumonia pneumoniae, aspiration pneumonia
confirmed secondary bacterial infections, antibacterial treatment
Non-­infectious Vasculitis, dermatomyositis, cardiogenetic pulmo-
lung disease nary edema, cardiac disease should be initiated to ensure broad-spectrum coverage. Antibiotics
should be tailored to drug sensitivity results.27 In patients with
Abbreviations: MERS, Middle East respiratory syndrome; SARS, severe
localized abscess, adequate drainage is required at the same
acute respiratory syndrome.
time to ensure healing.28
recommendations for the use of specific agents in accordance with 2. Fluid management: critically ill patients without shock should be
international and local guidelines. treated with conservative fluid management measures29; when
4. Monitor clinically: closely monitor vital signs and oxygen sat- septic shock occurs, volume resuscitation and norepinephrine are
uration; perform arterial blood gas analysis and review chest used to maintain mean arterial blood pressure (MAP) at 60 mm Hg
imaging as needed; monitor complete blood count, compressive or above.28
metabolic panel, C-reactive protein, and other biochemical indi- 3. Oxygenation: most pregnant women require an SpO2 of 95% and
cators of end-organ function and coagulation status. above to maintain adequate fetal oxygenation.30,31 Oxygen should
5. Identify the pathogen: ensure adequate supplies and measures are be given immediately to prevent hypoxemia and reduce the work of
in place to collect all necessary samples for pathogen testing. breathing and respiratory failure or arrest.32 Oxygen may be given via
high-flow or non-rebreather mask, according to the patient's clinical
condition. Humidification therapy devices, non-invasive ventilation
4 |  DIAGNOSTIC IMAGING (NIV), or endotracheal intubation may be necessary.33–36 In recent
years, clinically, the use of extracorporeal membrane lung oxygena-
Chest imaging is critical for the complete evaluation of COVID-­19 tion technology (ECMO) has been indicated to reduce the death of
infection and should not be withheld in pregnant women. Both patients with pulmonary infection,37–40 but its use during pregnancy
X-­ray and computed tomography (CT) use radiation. Impact on the should be limited and less invasive therapy initiated early, with the
fetus is related to the gestational age at the time of the examination aim of preventing and treating severe respiratory complications.36
8
and the dose of radiation exposure. Routine diagnostic imaging 4. Severe acute renal failure due to sepsis: hemodialysis may be
doses are much lower than 1  Gy, the threshold for early embry- required should severe sepsis lead to renal failure, and should elec-
onic injury.15, 16 There have been no reports of fetal malformations, trolyte imbalances be so impaired that they are life-threatening and
restricted growth, or miscarriage at exposures below 50 mGy.17 The unresponsive to conservative management.
minimum radiation dose associated with developmental delay is
above 610 mGy.18–21
According to data cited in clinical guidelines from the American
6 | PERINATAL CARE CONSIDERATIONS
College of Radiology22 and the American College of Obstetrics and
Gynecology,23 when pregnant women undergo a single chest X-­ray
6.1 | Fetal monitoring
examination, the fetus will receive a radiation dose of 0.0005–
0.01  mGy. CT is associated with a fetal radiation dose of 0.01– Electronic fetal heart rate monitoring and/or ultrasound should be
0.66  mGy.16 During the CT examination, intravenous iodine contrast used to evaluate the fetal status dependent upon the gestational age.
agent can enter the fetal circulation and amniotic fluid through the Doppler assessment for the presence of fetal heart tones will suffice
placenta, but animal studies have shown that it has no teratogenic or in the previable period. More advanced monitoring is recommended
mutagenic effects.24–26 once the fetus reaches viability. Routine diagnostic procedures such as
Due to a favorable risk–benefit ratio, X-­ray and CT should be used amniocentesis are not recommended in mothers with active infection.
for pregnant women as clinically necessary, with informed consent Should amniocentesis be considered as part of a diagnostic work-­up
obtained. Abdominal shielding and limiting exposure times to the min- (such as evaluation for intra-­amniotic inflammation and infection), the
imum necessary may reduce the total fetal radiation dose. risks and benefits of such procedures should be discussed with the
patient and appropriate informed consent obtained.

5 |  MANAGEMENT OF CONFIRMED CASES

6.2 | Delivery timing
While the actual clinical course in pregnancy with COVID-­19 is still COVID-­19 infection alone is not an indication for pregnancy
being elucidated, it is recommended that symptomatic pregnant termination, and decisions regarding delivery timing must be
 |
134       Chen ET AL.

T A B L E   2   Summary of management recommendations

No. Recommendations Quality Importance

1 Medical centers should standardize screening, admission, and management of all pregnant women Moderate Critical
infected with COVID-­19. Management should be coordinated in accordance with local, federal,
and international guidelines; the public should be informed about the risks of adverse pregnancy
outcomes
2 All pregnant women should be asked whether they have a history of travel to endemic areas or High Critical
contact with others confirmed to have COVID-­19 and should be screened for clinical manifestations
of COVID-­19 pneumonia
3 Pregnant women with suspected COVID-­19 infection should undergo lung imaging examinations High Critical
(CXR, CT) and diagnostic testing for COVID-­19 as soon as possible
4 Pregnant women who have a suspected or confirmed COVID-­19 infection should be encouraged to High Critical
report symptoms immediately. They should be screened promptly by qualified medical personnel
and directed to present to the appropriate hospital if clinically required. Hospitals with isolation
rooms or negative pressure wards should preferentially admit these patients into those units rather
than have the patient triaged and transferred between multiple clinics and facilities
5 For pregnant women with confirmed COVID-­19 infection, routine antenatal examination delivery Low Critical
should be carried out in a negative pressure isolation ward whenever possible, and the medical staff
who take care of these women should wear protective clothing, N95 masks, goggles, and gloves
before contact with the patients
6 The timing of childbirth should be individualized. Timing should be based on maternal and fetal well-­ Low Important
being, gestational age, and other concomitant conditions, not solely because the pregnant patient is
infected. The mode of delivery should be based on routine obstetrical indications, allowing vaginal
delivery when possible and reserving cesarean delivery for when obstetrically necessary
7 In pregnant women with COVID-­19 infection who need a cesarean delivery, it is reasonable to Very low Important
consider regional analgesia. If the maternal respiratory condition appears to be rapidly deteriorating,
general endotracheal anesthesia may be safer; multidisciplinary planning with the anesthesiology
team is recommended
8 It is currently uncertain whether there is vertical transmission from mother to fetus, but limited Low Important
cases have shown no evidence of vertical transmission in patients with COVID-­19 infection in
late-­trimester pregnancy. Neonates should be isolated for at least 14 d. During this period, direct
breastfeeding is not recommended. It is recommended that mothers pump milk regularly to ensure
lactation. Breastfeeding may not be safe until COVID-­19 is ruled out or until both mother and neo-
nate clear the virus. Multidisciplinary team management with neonatologists is recommended for
newborns of mothers with COVID-­19 pneumonia
9 It is recommended that obstetricians, neonatologists, anesthesiologists, critical care medical special- Low Important
ists, and other medical professionals jointly manage pregnant women with COVID-­19 pneumonia
and strictly prevent cross-­infection. Medical staff caring for these patients must monitor themselves
daily for clinical manifestations such as fever and cough. If COVID-­19 infection pneumonia occurs,
medical staff should also be treated in isolation wards
10 All staff engaged in obstetrics should receive training for COVID-­19 infection control High Critical

Note: The quality and importance of evidence reported in this paper has been adapted from the quality and importance of evidence criteria described in the
Canadian Task Force on Preventive Health Care (https://canad​ianta​skfor​ce.ca/wp-conte​nt/uploa​ds/2016/12/proce​dural-manual-en_2014_Archi​ved.pdf).

individualized. In most cases, the improvement of the mother's with severe COVID-­19 infection at 26–33+6 weeks of gestation, the
condition will improve the fetal status. Ideally, if women can be safety of the mother and fetus should be taken into account. At a
successfully treated, pregnancies should be allowed to continue gestational age of 34  weeks or above, the fetus likely has a high
to term. Conversely, if a pregnant woman is critically ill, her clini- intact survival rate and late preterm delivery may be considered.
cal deterioration may lead to intrauterine fetal demise or loss of Before any preterm delivery, antenatal corticosteroids and mag-
both mother and infant. In such circumstances, early delivery may nesium sulfate for neuroprotection should be given to any mother
be warranted. The indications for early delivery depend upon: with a potentially viable fetus. The risk of vertical transmission dur-
the mother's clinical status; gestational age; and fetal well-­being. ing peak infection and while symptoms are very acute is unknown,
Pregnant women who are critically ill due to COVID-­19 infection in and maternal antibody production and passive immunity may not
the previable period (which varies regionally, generally <26 weeks yet have had time to develop. Therefore, early delivery should be
in China, <23–24 weeks in the USA) may require early delivery as a recommended only as the risk–benefit ratio to the individual mother
life-­saving measure, despite a high risk of neonatal death. In women and fetus demands intervention.
Chen ET AL. |
      135

close contact with others, reduce participation in large-­scale

6.3 | Mode of delivery
public events, dinners, and other places with large crowds.
Delivery should be performed in a negative pressure isolation ward 2. Be proactive: stay abreast of the latest recommendations regarding
whenever possible. Movement between the patient's antepartum COVID-­19 infection.
treatment room and dedicated operating room should be limited, and 3. Those with suspected symptoms should seek medical treatment
the patient should wear a surgical mask outside isolation rooms. The and follow all recommendations regarding treatment and contact
mode of delivery should be based on the usual obstetric indications, isolation in accordance with their doctor's advice.
as there is no clear benefit of delivery via cesarean in women with
COVID-­19 infection. Regional epidural anesthesia or general anesthe-
sia can be used for delivery in pregnant women with COVID-­19 pneu- 7 | CONCLUSION
monia, and the decision about mode of analgesia should be discussed
with the anesthesiology team. If intubation is required due to poor Recommendations for managing pregnant women and neonates born
maternal status, general endotracheal anesthesia should be used for to mothers with suspected or confirmed COVID-­19 infection are sum-
cesarean delivery.36 marized in Table 2.

6.4 | Placental disposal AC KNOW L ED G EM ENT

The placenta of pregnant women with COVID-­19 infection should We would like to thank Catherine Eppes, Karin Fox, and Michael

be treated as biohazardous waste; when the placental tissue sample Belfort for essential revision of this manuscript.

needs to be tested, it should be disposed of according to local and

national regulations. AU T HO R CO NT R I B U T I O NS

DC and HY initiated the study; DC wrote the draft based on expert

6.5 | Neonatal care advice for all authors in this manuscript.

Delayed cord-­clamping for neonates born to pregnant women infected

with COVID-­19 is not recommended and the neonate should be CO NFL I C TS O F I NT ER ES T
cleaned and dried immediately. Previous, limited data on pregnant
The authors have no conflicts of interest.
women with SARS-­CoV infection have shown a low probability of ver-
tical transmission from mother to fetus.41, 42 A single case of COVID-­19
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