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COVID in Pregnancy

Oct 27 | 12:30 PM

So far, our experience with COVID-19 suggests that pregnancy worsens symptoms in COVID-19 positive women. These women are more likely to have poor pregnancy outcomes, such as pre-term delivery or miscarriage. Join us as Dr. Swati Gawai discusses these outcomes and methods for avoiding such poor outcomes.

[Music] uh good evening everyone my name is dr devanchen and i welcome you all on behalf of the netflix uh today we have with us a very ambitious personality dr swati gaway assistant professor department of obstetrics and gynecology at rookman airport medical college and sign hospital welcome ma'am thank you thank you so why we are we are studying this topic we have to reduce the transmission of forward to pregnant women and because of pregnant women husband family members as well as the healthcare workers are also affected so we have to see for the provision of safe and personalized woman-centered care during pregnancy birth and early postnatal period during this cohort as well as we have to trade iterate the suspected or confirmed cases of 49. so what is code 19 it is a viral disorder because of a virus of strain of coronavirus it was first identified in gohan city of china towards the end of 2019 november 2019 so other corona viruses are also there let's see it's h corona whereas 43 hku and all so this causes mild to moderate upper respiratory illnesses mers and stars are similar to are the parts are just coronavirus so diagnosis it can be made based on the symptoms and known exposure or it simply can be tested by antigen or antibodies so what is the epiderm epidemiology till date there are four strains of coronaviruses out of which this delta variant is recently found and it is very morbid it causes increased admission it causes increased admission in icu and it leads to mortality it is a new variant and recently 90 percent of the samples were found to be delta virus in iso patients in uk so transmission from human to human transmission uh it is also same in the droplets secretions and pieces for mites it occurs most often uh through close contact with the infected person or the contaminated surfaces with regard to vertical transmission uh it is found that vertical transmission does occur but it is very rare uh if it does occur it it appears to be not affected by mode of birth or delayed cord clamping or skin to skin contact or method of feeding or whether the woman and babies stay together so it is not related to this however there is an evidence of trans placental transmission of antibodies against 19 following metanal infection so presence of immunoglobulin gene in the umbilical cord blood sample suggests that passive immunity might be transferred to the neonate ight levels in the cord blood have been reported to be higher with longer intervals between maternal infections and delivery the duration of immunoglobulin g antibody presence and whether this truly confers passive humility is unknown so what are the effects of covert 19 on pregnant women so most of the most of the women are symptomatic and the woman who experience uh few symptoms they are mostly mild to moderate like cold or flu-like symptoms uh these symptoms are cough fever sore throat dyspnea myelogen loss of sense of test and diarrhea so two thirds are asymptomatic and compared to non-pregnant women pregnant women have higher rate of ico admission it is because of the lower thresh threshold for admission to icu rather than more severe disease they have higher need of ventilation and extracorporeal membrane oxygenation those who require hospitalization have overall worse maternal outcomes including an increased risk of death although the risk of death remains very low in uk it is around 2.5 in india it is around 1.5 to 1.8 so frequency of severe illnesses in pregnant women they may be at increased risk of complication in third trimester the most because of leading to respiratory distress syndrome or sepsis or septic shock or pulmonary embolism though mild diseases are all through the patients who are having mild disease with no evidence of pneumonia or hypoxia we can categorize them as mild moderate and severe the moderate disorders uh include viral pneumonia severe requiring oxygenation and admission in icu and those are critical they can have acute respiratory distress leading to mortality so what are the risk factors the patients are having bmi more than 30 kilogram per square meter or pre-pregnancy co-morbidity such as pre-existing diabetes or pre-existing hypertension the mother's age is more than 35 years of age or in low socioeconomic strata where congested areas are there no proper facilities are there or the health care workers like doctors dark nurses and all the hospital and uh people they are also tires it has been observed that asian and black or ethnic minority minority are more at risk of it so how does it affect pregnancy so it to the baby it is it relates to premature birth it may be associated with increased incidence of small for gestational age and because of this there is increased risk of neonatal morbidity for the babies as well as mortality skill work is also seen though it is rare but it is definitely it is more than uh in non-covered mothers so what are the effects on maternal and perinatal outcome due to the change services in last two years we must have seen that because of lockdown and all the antenatal pregnant women they are not able to have proper international visits so the services are definitely changed because of the anxiety also they were not coming and the provision of paternity services uh where little uh reduced they were apprehensive so we should reduce the antenatal and the the appointments were reduced and the consultations were also reduced so we should give we can give them telecom tele consultation or video consultation this is this is very new for because because so vaccination uh four vaccines two two four hobby shield and coaxial in india in this four vaccines like pfizer as well as income modernity and jensen all are very effective around 95 percent uh efficacy with two doses this is little you can zoom this slide this this is an indian poverty vaccine so two doses this previously the interval was 28 days now it is 84 days for four we shield and 28 days for covaxian so we can give in person we can uh clinical appointments can be given to the such pregnant woman or we can share our numbers and ask them to report if any symptoms related to cohord are there all these things should be discussed with the families of this pregnant woman and the pregnant woman who have been hospitalized or have confirmed the code 19 should be offered thromboprophylaxis for 10 days following hospital discharge and a longer duration of prophylaxis can be given if persistent morbidity is there so the uh vaccines in uk uh this paisa and modena they are mrna vaccines which protein is produced is introduced into the person via lipid nanoparticle code the mra does not go into the nucleus of the his host cell so it remains separate from the host dna and the host then produces the spike proteins and these proteins elicit a protective immune response similar is for kobe shield also the mrna from the vaccine is broken down by the host cell within two days then later on this jensen vaccine these are viral vector viral vector vaccine in which the dna encode this rs4 to protein in the person when they are vaccinated using a modified and adenovirus vector the vector has been modified so that it cannot replicate and the spy protein is not expressed on the adenovirus itself the adenovirus vector serves only to deliver the spike dna to the host cell so that it can elicit a protective immune response vaccine safety the adverse effect profiles of all the available vaccines are similar most participants in the trials have been seen to have minor local reactions like pain redness or swelling at the injection site mild symptoms uh like fatigue headache myalgia were also common and these were typically short-lived about 10 to 20 of the participants had a fever after vaccination so in general uh the adverse effects are more common after the first dose than the second goes for the estrogen card similar for the kovi shield also then modern iron physical so these vaccines have continued to be monitored for safety after their authorization and an association has emerged between oxford esta centre and rare cases of thrombosis is seen very rare reports of myocarditis and pericarditis are also seen by pfizer and moderna so what is eligibility for vaccine in pregnancy vaccination is strongly recommended it should be offered to pregnant women at the same time as the rest of the population based on the age and clinical risk the pregnant woman should be offered uh whatever is available this is your case study these are associate guidelines so cohesion for vaccine anything can be given whatever is available so the potential fetal and maternal effects uh my mother maternal effects are minor and short lives like soreness headache fatigue systemic features like fever fever have appeared more commonly non-pregnant women but pregnant women did report nausea and vomiting with my which might be related because of pregnancy only so what what is this vaccine-induced thrombosis and thrombocytopenia it has been reported by reported after estrogen that is covisheld it is an unpredictable idiosyncratic vaccine reaction similar to heparin induced thrombocytopenia and thrombosis associated with heparin therapy it is not associated with any visual usual venous thrombosis thromboembolism risk factor it is usually seen after within 5 to 28 days after the first dose particularly in adults younger than 50 years of age although pregnancy increases the risk of coagulopathy there is no evidence that pregnant or postpartum women are at higher risk of vaccine-induced thrombosis from the so it is extremely low one in one lakh for a covey shield then there is no risk for pfizer fetal effects uh following uh this rna vaccination that is co-vaccine they appear similar to the other groups in uh prior to the onset of cognitive that is those who are not vaccinated the most common adverse effect with freedom hearts multiple gestational age and congenital anomalies none of the mothers whose babies were born with congenital anomalies had received four nanking vaccine in false transistor or periconceptional fillet spontaneous miscarriages are also seen and most commonly these are first trimester miscarriages antibodies in neonatal cord blood and in breast milk have been found following code 19 vaccine it may therefore be that passive immunity is confirmed vaccine elicited antibodies have also been found in infant cod blood and breast milk following the administration of over 90. the degree of protection because of these antibodies to the pneumonia is unknown so recommended vaccine timing in relation to stages of pregnancy and lactation timing during pregnancy it can be given at any time breastfeeding women can receive cover 19 vaccine there is no need to stop breastfeeding to the vaccine there is no evidence to suggest that code 19 vaccine affects fertility so women who are planning pregnancy or fertility treatment can also receive cover 19 vaccine and do not need to delay conception just because they have taken vaccine postpartum it is just same like any other non-pregnant female they should be offered vaccination hasn't been possible during breastfeeding it can be given at any time there is there is though there are lack of safety data for the available vaccines related to breastfeeding but there is no possible mechanism by which any vaccine ingredient could pass through the breastfeeding well through breast life so women should therefore not stop respiting in order to be vaccinated against over 19. so timing for women who are planning a pregnancy undergoing fertility treatment no evidence to suggest that it affects fertility therefore there is no possibilities there is no possible mechanism by which vaccine could cause an impact on the fertility do not women do not need a pregnancy test before vaccination and women planning a pregnancy do not need to delay pregnancy after vaccination and this vaccine showed that administering these vaccines and rats had no effect on fertility this modern iron high sermon so animal studies have shown no effect on fertility for estrogen also the theory that they related to the spike protein could lead to fertility problems is not supported by any evidence most people who contract over 19 will develop antibody with the spike protein and there is no evidence of fertility problem in people who have already received coca 19 so various societies like british society and the productive society have advised people of reproductive age to have coordinated medicine including those individuals who are trying to get pregnant or planning pregnancy the advice that woman can have vaccine during fertility treatment and there is no need to delay treatment uh what should be counseled to the pregnant woman it is always an informed decision which we cannot force them to take vaccine current clean current scenario so there is an excellent evidence of vaccine efficacy with about 98 percent of the woman who were admitted to hospital and requiring treatment for food having had not taken the vaccine so those who have taken vaccine are those they can get uh who weight but they are comparatively safe so an informed decision should be made about vaccine the timing of vaccination the benefits and risk of vaccination and everything the risk of declining vaccination everything should be explained to the pregnant woman as well as her family so what what what do we have to counsel they we have to give them option that whether they can have the vaccine now or they can decline the vaccine with keeping an option open to take the vaccine in future or they can decline the vaccine all together it is an individual choice but before giving them choice we have to tell them the benefits of vaccination so reduction in severe diseases of pregnant women those who are vaccinated potential reduction in the risk of free time was associated with covert 19 potential reduction in transmission of poverty 19 to vulnerable household members reduction in the risk of stillbirth associated with covet 19 and protect the potential protection of the newborn from covenanting by passive antibody transfer so these are the benefits and let them choose then whether they want to take it or not not take it the risk minor local reaction mild adverse effect like fatigue fedex myalgia thrombotic adverse effects whatever there has been no evidence to suggest fetal harm following vaccination so there is no harm in taking vaccines so it can be always advised the risk from covet 19 if the pregnant woman declines vaccination maternal risk the risk of illness from cover 19 is higher to pregnant women than for the non-pregnant woman requiring admission is also higher requiring isu is also more those were not vaccinated in pregnancy fetal risk two to three time increase risk of freedom birth still what is also almost double than the normal population so this should be personalized to each individual uh with risk of exposure because of occupation like for healthcare workers because of public facing roles and education setting risk of severe illnesses because of medical morbidities like hypertension diabetes obesity so research is ongoing for poverty in pregnancy addressing aspects of immunity safety different vaccines optimal schedules for protecting women the only aim to identify the most effective the only aim is to identify the most effective schedule in order to protect the pregnant woman as well as other aspects such as whether or not vaccines improve immunity convert to breast milk so what antenatal care is to be taken during covet pandemic organization of antenatal care so they should be advised to continue their routine antenatal care it may be modified unless they meet self-isolation criteria for individuals or households with suspected or confirmed coordinating service modifications are required to enable social distancing measures and whether possible good ventilation to reduce the risk of transmission between women staff and other clinic or hospital visitors to provide care to the woman who are self-isolating for suspected or confirmed coordinating for hospital attendance is an essential so this nice recommend schedules of antenatal care should be offered in full like previously whatever we were practicing should be there so ideally where save this appointment should be offered in person particularly for those living in medical social or psychological condition that put them at higher risk of complications and adverse outcomes during pregnancy so the staff should be properly trained to treat or take care of such covered patients there can be some problem because of mass [Music] that means that might prevent lip reading or there can be some problem for deaf people so basic assessments like blood pressure measurement urine testing assessment of fundal height and those women who are not receiving serial fetal growth or ultrasounds are still required and we have to plan these strategies to ensure that women are able to receive this monitoring even when the entire care provided is removed so it is considered more appropriate for the appointments to be conducted remotely this teleconferencing with the conferencing can be done some limitations can be there because of lack of internet facilities or internet access we should be aware that the woman having unvoiced concern regarding their care if they have contact in the person we should be aware that the woman may not have the privacy within their home to disclose some private personal and sensitive information in clinic they can tell you everything when they have to call you from home sometimes they may not be able to tell about domestic violence social wise sexual or physiological abuse psychiatric illness so these things require personal appointments though they should be arranged apart from that blood test maternal examinations ultrasound they also require personal visits so it should be arranged appropriate screening for medical disorders like diabetes hypertension should be done and consideration should be given to women who have poor morbidities making them vulnerable to the effects of overnighting waiting areas should not be shared there should be separate areas for poor patients wherever possible they should be cared for in a single room they should be able to notify the unit regarding non-attendance and if they have missed any visit or any investigation because of isolation then at earliest it should be made available once they are free of covered or they are detected negative of gold so sometimes the women receive the antenatal care at different sites so we should must ensure that all the information regarding them is properly documented records are there electronic or hard copies are there and it should be provided to them so all everything should be based on triage services the woman who have more symptoms like moderate to severe symptoms should be admitted mild and asymptomatic patients can be sent through community care should be maintained antenatal appointments and otherwise the women who are at higher risk of developing severe complications should be given attention and the doctor should discuss the risk with such woman and that should be they should be encouraged to seek advice without any delay if they are having any symptoms of provide and for such patients we should lower the threshold to admit and consider multidisciplinary treatment in such high risk moment they should continue to take folic acid vitamin d uh influenza vaccine also to protect them from flu during pregnancy and as well as to pass on the immunity to the baby they need to continue at least whatever support advice care and guidance for pregnancy child work for parenthood whatever they were having previously previously pandemic they should continue to receive that and special attention should be given uh those who are having the any abusive problem domestic abuse sexual psychological homelessness or mental problem so staff should be properly trained they should be aware of the increased risk of abuse in pregnancy because in last two years it has been observed since because of lockdown everybody is at home so there is increased incidence of domestic abuse in females so we should be asking for each visit we should be asking about this abusive history or if anything they want to tell us they should be encouraged to share any concerns at every opportunity and be provided with advice and support on how to access the appropriate services whatever help they require should be provided to them and they should maintain in-person appointment in woman when they are safeguarding concerns in order to provide extra so because of this point pandemic other thing is found that there is increased level of anxiety and mental health problems in pregnant women so we have to ask about this also every time and many times we are very anxious that they not able they are not able to visit as frequently as they could apart from that they are they have concerns about their baby and then they have concerns about themselves if they get forward and certain red flag signs are there those who have suicidal thoughts or any history in the family then they are very anxious and apprehensive so proper guidance should be given to them and everything should be based on tragedy [Music] so if women report symptoms attributed to covered on phone then immediately they have or any symptoms like keyword cough we can ask them to get their test but we should not come directly through the diagnosis of forward we have to pull out urine intact infection causes of basic causes of fever also then if the symptoms are suggestive of cover 19 get their antigen test done and we assess the severity of the illness of the woman this assessment should be based upon the symptoms and clinical and social risk factors and various escalation pathways this shouldn't include safety netting advice about the risk of deterioration and when to seek urgent medical advice so for women with possible or confirmed code maintain hospital attendance is required or for uh who self presents because of the family history of kobe 19 they should be advised to attend uh with the step in a separate vehicle if an ambulance is required then a proper separate ambulance for a food patient should be there and that should be met at the unit or hospital entrance with a staff wearing pp kit and provide the woman with the proper surgical mask and the staff should be wearing it a woman should be cared for in isolation room so antenatal care in women who those who have recovered from covered can we put the pole here so should forward vaccination be included in anc care program yes okay i think in few years in next one or two years it will be included should i have the next problem next house you can run should the vaccination be included in infant immunization program yes yeah but i think uh vaccination for infants should not be included now because already they are not having there are no studies that it is transmitted and if at all it is transmitted then they are not symptomatic they don't have any symptoms we can keep them with the mothers and even after that if vaccination is given also then it is very short-lived it is not long term or lifelong immunization so i don't think the scenario can change in few years but currently as of now i don't think that it should be included so for women who are recovered with mild moderate and no symptoms uh the care should be same as those who are non covered it remains unchanged following the period of self-isolation and those who have missed the appointment should be checked for whether intrauterine growth retardation is there so we can do serial monitoring of ultrasounds and those who are recovered from serious or critical illness uh requiring admission and supportive therapy so they should be given proper uh with a dynamic and for proper physician they should be assessed before discharge and those who are very critical and require ico and ultrasound should be done at least approximately 14 days following recovery from their illness and if any pre-existing reason is there to get it done earlier then it can be done earlier so venus thromboembolism since the woman in lockdown they were at home and not mobile so we asked them to be hydrated and the risk is assessed infection it can be considered as a transient risk factor for assessment and when uh when normally indicated it should be continued this from the prophylaxis the patient who are already having uh bbt they can be uh they can they have to continue from vocabulary so women who are self isolating should be continued uh at least between seven to fourteen days till they have recovered and all symptomatic women admitted with confirmed or suspected coordinating should of it should be offered lmw that low molecular weight repairing unless the birth is expected within 12 years because it will cause increased bleeding so with severe complications the appropriate dosing should be discussed with the physician a senior obstetrician and the expertise in managing the embolism so those women who have been hospitalized and have confirmed the cover 19 should be offered number prophylaxis for 10 days following hospital discharge it can be increased for those having uh consistent morbidity those who are admitted will confirm the suspected ninth over 19 within six weeks postpartum they should be offered from a prophylaxis for the duration of their admission and ten days after that also it can be extended until six weeks if the morbidity persist so during labor and birth so low risk woman those who are test positive within 10 days are asymptomatic should be constant about the risk associated those who test positive on admission this continuous electronic future monitoring and the acidity that is cardiotography is not recommended just because they are positive if for other obstetric reason it has to be done then it is it has to be done this critical monitoring options should be discussed with the woman acknowledging the current uncertainties in women who are symptomatic because suddenly they can have uh respiratory distress suddenly or symptomatic woman can get into this so woman who test positive should be offered the lead card clamping and strengthening contracts that would be just like as normal obstetric patients so suspected or confirmed code 19 in labor so they should be considered positive it can be suspected there if their mild symptoms are there then we can encourage them to remain at home till active labor commences and otherwise signs and symptoms of labor we have to ask them to visit the hospital and admit them if the patient goes in active labor pp kit is advisable uh woman with symptomatic suspected or confirmed or invented to be advised to labor and give birth in a proper facility proper uh setup where facilities for coordinating patients are there so full maternal and fetal assessment should be done on admission uh we have to check for the temperature respiratory rate oxygen saturation and you have to confirm the onset of labor continuous electronic return monitoring not that means if it is in labor we can do it just like for normal any other patient the um inform the anaesthetist uh street sisters consultant neonatologist and neonatal nurse infection control team and such patients are admitted others we can physician or respiratory physician can also be income so early maternal observation and assessment should be done for oxygen saturation and temperature and oxygen therapy should be titrated to aim for saturation above 94 percent maternal infection in itself is not a contraindication for performing fetal blood sampling or using fetal scalp electrodes the number of staff members entering the room should be minimized to minimize the spread of infection so labor and work for a woman who have recovered from povert 19 it is all just same as uh non-covered patients those who have completed self-isolation there should be no change to planned care during labor and work those women who have recovered from hospital admission for serious and critical coordinating healthcare professionals to discuss and plan for birth of such patients and personalized assessment should be made depending upon the woman's uh associated probabilities growth scan should be done and if there is a disclaimer this lag between the ultrasounds then we have to get the doppler done so both partners if partners are negative then they can come and be with the patient in labor with a mask those who are symptomatic or in a period of isolation they should not be allowed and local risk assessment should be made the partner should be asked whether they have experienced any symptoms of over 19 in the preceding days like key work of loss of test or smell if they had symptoms in last 10 days they should be asked to leave the unit and self-isolate and unless they get a negative test and if they have fever in the last 48 hours then they should be asked to leave not to accompany even if the test is negative so now both the partners not otherwise advised to be ourself isolating should be allowed to stay with the moment through the labor throughout the labor unless general anesthesia is given for cesarean section so they should be wearing face masks they should not walk around in the water hospital should wash their hands frequently restrictions on the visitor should follow local hospital policies and we should prioritize the birth partners of women who require continuous support such as women with disabilities communication like deafness or physical disability or mental disorders or some social factors are there so timing and mode of birth they should be discussed with the forward mother as well as her family consideration should be given to her preferences and she should be told for any obstacle indications for any interventions are there so assessment should be taken whether it is beneficial or overall to delay a planned cesarean birth like if previous two cesarean is there then we have to plan the uh date of cesarean section in such case so we have to consider for urgency of the birth and the risk of infectious transmission to other women health care workers and postnatal natalie to her baby as well if this is any section of induction or induction cannot be delayed uh we have to follow the advice for services providing care to women with worsening symptoms or who are becoming exhausted should be offered personalized then they have to decide if the patient is very exhausted then you can offer her the information and she has to take the decision senior person observation should be there and whether we have to assess when to talk is there another is time consuming but it is essential and it may impact on the time it assists in the birth of the baby so how to manage obstetric theaters there should be separate theaters ideally for towards patients operation theaters so for elective procedure uh lex uh cesareans are cesarean section or soft large it should be scheduled at the end of the operating list preferably it should be a separate letter the number of staff talks should also be minimum to avoid translation so for managing critical patients pregnant and postpartum woman should be investigated and treated say as just like non-pregnant woman the decision of admission depends upon the symptoms so if patient is mild or asymptomatic and is able to monitor oxygen saturation of at home when she can present at home fever should be evaluated for other reasons of bacterial sepsis in pregnancy also testing should be offered in addition to blood culture testing of science forward too we should not jump to the diagnosis of proving in all patients with fever in pregnancy bacterial infection should be considered if wbc is raised because usually the lymphocytes are less an antibiotic should be started radiographic investigation can be performed in as for non-pregnant patients like chest x-ray and ct it is essential for evaluation of an unwell movement with 4019 and it should it should be performed when indicated and then it should not be delayed because the concern of the baby so diagnosis of pulmonary embolism and heart failure should be considered for women presenting with chest pain worsening hypoxia respiratory rate if it is more than 20 breaths per minute particularly if there is sudden increase in oxygen requirement or in women you are who have breathlessness or it persists for persons after the expected recovery from 419. additional tests we can do like ecg eco city and geogram pulmonary angiogram vp lung scan ferritin and c reactive protein are usually raised in 49d diameter is also raised dic can occur with prolonged pt and a and apt that is activated partial thromboplastin and no fibrinogen levels so women with suspected covet 19 should be treated as a positive until test results are available the priority is to stabilize the woman so origin multi-disciplinary treatment meeting multi-disciplinary team meeting should be arranged and we have to maintain the oxygen saturation between 94 to 98 percent those women with respiratory rate about 20 heart rate more than 110 immediately they should be put twice you the great key priorities for medical care of the woman and her baby are the woman and her baby and the birth differences concerns among the team regarding special consideration in pregnancy including the health of the baby concer a consultant in aesthetic in gynecology should review all the pregnant and recently pregnant women with suspected so they should be proper needs and forward awards heart rate respiratory rate oxygen saturation we have to be aware that the young fit one can compensate for deterioration in respiratory function and are able to maintain normal oxygen saturation until sudden we have seen in lot of patients that there is sudden decompensation in forward patients they are all symptomatic or mildly symptomatic and then there is certain respiratory decomposition so we have to keep an escalation plan in hand so woman's care should be escalated urgently if the oxygen requirement uh is increased or if fio2 is above 95 percent about 35 sorry increasing the respiratory rate despite the oxygen therapy off or about 25 degrees per minute or rapidly rising respiratory rate there is reduction in the urine output when this is being monitored and there is acute kidney injury creatinine levels about 77 micro moles in women with more existing pre-existing general disorders there is drowsiness even if the saturations are normal possibility of myocardial injury should be considered as the symptoms are similar to those of respiratory complications the appropriateness and frequency of fatal heart attack monitoring should be considered on an individual basis accounting for the gestational age so planning for the birth of the babies the woman should be advised and should be given a proper knowledge about the risk factors and forward and it's required emergency cesarean section or induction of labor and the facilities to uh maternal resuscitation as well as fetal resuscitation should be available if maternal stabilization is required before delivery it can be taken safely this is the priority if urgent intervention of what is indicated for critical reason then the watch should be expected for mutual often optimism like how we do for any other operative integration like with placenta freely of bleeding then we have two daily given research rupees when nitrogenic freedom what is required steroids can be given to promote language index should not be delayed if required oxygen is given to maintain saturation either can either bionasal cannula face mass ventricular mass c5 ippb or extracurrial membrane oxygenation pruning is strongly considered but it is not possible in third trimester so take 28 weeks we can ask them to lie down in front of position there there is limited evidence uh that this is visible we should uh caution should be applied for iv fluid management in the even if they confirm the emission should remain open for the possibility of another coexisting disorder sometimes forward is there accompanied with some other infection so we should be open for other comorbidities also so there should be no delay in administration of any of the therapy lmwh should be given it should be considered on individual basis if there is prior history of or any other risk factor when it should be it should be given thrombocytopenia is associated with severe uh covalent infection if it is less than 50 then aspirin and lmw should be discontinued to avoid excessive bleeding especially if the patient is near down mechanical aids like pneumatic compression should be used if lmw therapy is contraindicated or caused secondary to thrombocytopenia steroids can be given for 10 days or a discharge which is for women who are unwell and requiring oxygen supplementation with ventilatory supports uh once the one suggested regimen is steroids are not indicated then we can give them redness salon once a day or iv hydrocortisone 18 milligrams a day for 10 days or until discharge if steroids are indicated then dexa or beta can be given six milligram every 12 hours for four doses 12 milligram for 24 after two doses after 24 hours it can be followed by oral pregnancy on 40 milligram once a day or iv hydrocortisone 80 milligram twice a day to complete total of 10 days or at least or until the discharge whichever is sooner so intelligence receptor antagonist oscillation has been shown to improve the outcomes including the survival in hospitalized patients with hypoxia oxygen saturation below 92 percent on air or requiring oxygen therapy and evidence of systemic inflammation that is crp is more than 75 million so it is shown to be very helpful in pregnant women also the data in the situations are limited there is no evidence that it is stereogenic or pseudotoxic but fda has approved its use for an emergency administration for during this time level for women meeting the above criteria that is hypocentric inflammation it is strongly considered it is recommended that any decision to create with intelligent intelligence agent should be taken by a multi-disciplinary team including obstetric infection and all other specialists respiratory physicians so this is region 4 2 similar to silicon these are also monoclonal antibodies iv infusion is given in pregnant and breastfeeding human treatment if they are symptomatic hospitalized with coordinating and have no charge through it to antibodies them this is very it may be considered in pregnant women 419 if the woman is not improving or if there is deterioration so we should be aware that the fetal risk profile of remedy is largely known this is also fda approved only for emergency administration during this poor these drugs which were previously used hydroxychloroquine and return away from nicely are ineffective and are not considered now last year we had used these drugs postnatally women and their healthy babies should remain together in immediate postpartum period if they do not otherwise require mental health critically if the mother is in icu then it's okay otherwise immediately roommate industries and normal uh postpartum human being advice should be done with the woman who has suspected or confirmed it should remain with their baby and be supported to practice skin to skin or care the baby requires uh ventilation or icu then it is different so we have to adopt these precautionary approaches for women who are suspected of coordinating and the babies need to be carried in an ico to minimize any risk of women to influence staff transmission at the same time so we have to involve the family partners parents and uh problems for the baby's health well-being and breastfeeding bonding attachment everything has to be counseled to this so women who test positive for sas go through during their maternity admission but who are not unveiled before need only self isolation for seven days women should be supported to make an informed decision to feed their babies and who choose to breastfeed should be supported to do so you know even if they have probably confirmed so advice regarding infant feeding it should be individualized they should be given proper advice guidance and support the family should be informed they should be supported and there it is their more choice to decide on feeding the risks and benefits of treating the baby in close proximity to the individual mixes it should be discussed when a woman is not well enough then either we can give the express breast milk or we can ask we can help get a donor breast milk or we can use a breast from formula fading but you can ask some caretaker to feed the baby so what are the precautions to be taken to limit the viral spread so we have to wash the hands before touching the baby breast pumps or bottles avoid coughing sneezing on the baby while treating consider wearing face coverings or fluid resistant face masks while feeding and caring for the babies the baby should not wear the mask because they are at risk of when women are expressing breast milk in hospital a dedicated form should be there for a forward mother so we have to adhere to the recommendations for pump cleaning after issues uh we have to keep it sterilized you know those for the babies who are bottle fed with formula or expressment and we can consider asking someone else to feed the baby who will care for the baby when a woman has given birth all members of household are recommended to self-isolate at home for 10 days women and their family should be advised about safe sleeping and smoke-free environment which are clear advised about careful hand hygiene and infection control measures at home so family should be guided on how to identify the signs of illness in the in your bond or worsening of their own symptoms and should be provided with appropriate contact details if they have concerns or questions about their babies the baby is not feeling well you can browse even here to check for the baby's status also so take home message will be we have to provide personal hygiene and care toward getting the disease itself primarily and maybe in upcoming years this immunization in pregnancy immunization of forward 19 vaccine pregnancy could be in the schedule like just how we give kittens see that so it would be in the schedule so these are my references all rco ji print of guidelines and uh aims guidelines and mhfw guidelines of government of india thank you thank you ma'am i will take some questions now domain name is advisable is advisable it is good for the baby as well as the mother dear doctor can you finally share the possibilities of any complications there is a question any complication in subsequent pregnancies subsequent pregnancies after forward virus infected pregnancy since the coverage is there since last two years so i have not come across any mother who has become pregnant within two years so the data is not there regarding subsequent pregnancies i don't think there would be any effect on subsequent pregnancies also and there was a question asking what about monoclonal antibodies in pregnancy antibodies in pregnancy the data is actually not there means we don't have patients who have underwent such trial to check the antibodies okay and is it safe to administer uh lambda evidently both in a pregnant woman so it is not safe to administer actually but we have to consider the risk benefit ratio if the mother is near term then we can deliver the mother and give her mbc or silicon citosilicoma it was already fda approved since 2010 for rheumatoid arthritis so it is not that pregnant women have not received frustration they have received it but not for pover so they have received it for arthritis so as such there are no adverse effects for the baby have been observed in last 10 years so for forward actually there are no studies but it is uh fda approved just for emergency administration now okay pregnant woman didn't be vaccinated yes all pregnant women should be vaccinated usually there is no timing they can be vaccinated at any time but in india we are recommended at least recommending at least after 12 weeks they should be vaccinated after all the organization there was a question is there a risk of thromboembolic episodes uh even after recovery yes yes yes even after recovery there is a risk around for 28 days the risk is definitely there endometriosis laparoscopy chances of through ivf so it depends whether what condition was there so what is what and what type of endometriosis was there and was it treated completely was it removed completely so if the endometriosis is completely removed like if the endometriotic cyst was there and it is completely removed then there are chances she might not require ivf also the endometriosis endometriosis is very fluoride and it has involved the endometrium all the peritoneal cavity then uh it depends they write those in critical covariate pregnancy doctor steroids i have already told uh i've already told if it is indicated for the status then same for mother for forward we can give 100 milligram iv then we have to give it at least for 10 days and if the patient is discharged sooner then we can stop it 80 milligram moral can be given how to risk stratifying when to go for cesarean section or normal so the mode of delivery should not be dependent upon forward condition uh the the decision should be purely basis based on the obstetric condition if it should not happen that just because the patient is forward then we have to do what's easier infection we can do uh normal delivery for uh patients just like how we do in other patients if any risk is there for cesarean like if previous two is there placenta previa is there then we have to do cesarean sections otherwise we can induce also such kobe patients for normal trial if they have not gone into labor then we can induce pregnancy future pregnancy till now the studies are not there and i don't think that there will be any effect in future pregnancies there is like a future fertility also so future pregnancies also i don't think they are related with the patient had over in this pregnancy all right thank you so much for this comprehensive session as you can see in the comments people were very happy with the session and we hope to see you soon hormonal imbalances and there are no studies with pregnancy we are studying for hormonal imbalance i don't think i have seen any passion for horrible imbalance i think within next five years we'll get a better idea about all these other issues all right no issues uh ma'am we hope to see you very soon and thank you so much everybody for attending and for presenting we hope to see you soon

BEING ATTENDED BY

Dr. Darius Justus & 882 others

SPEAKERS

dr. Swati Gawai

Dr. Swati Gawai

Assistant Professor Obstetrician , Gynecologist and Endoscopist at LTMMC and Sion Hospital, Mumbai.

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dr. Swati Gawai

Dr. Swati Gawai

Assistant Professor Obstetrician , Gynecolog...

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