Covid19 and pregnancy

1
COVID19 AND PREGNANCY
Dr. Shivani Sachdev Gour M.D. DNB, M.R.C.O.G.
(UK) Dr. Nupur Garg M.S. (Obs Gyn) F.R.M
2
KEYPOINTS

• Introduction
• Virology and Epidemiology Clinical Manifestation
• Prevention
• Course in pregnancy
• Approach to diagnosis
• Prenatal care
• Management of Labour and Delivery PP care
• Abortion/ MTP/ Ectopic Pregnancy
• HCW Prophylaxis

3
Introduction

• Coronaviruses are family of enveloped,
  single-stranded RNA viruses mainly cause mild
  symptoms like common cold
• At the end of 2019, a novel coronavirus was
  identified in a worker in Wuhan Sea food market
  in the Hubei Province of China who had pneumonia.
• It was observed that this strain exhibited
  stronger virulence and quickly passed
• from human to human
• In Jan 2020, the WHO designated the disease as
  public health emergency
• It designated this virus as 2019 Novel Corona
  virus later it was renamed as
• severe acute respiratory syndrome coronavirus 2
• (SARS-CoV-2) previously, it was referred to as
  2019-nCoV.

4
Corona Virus- Notorious past History

• 2 epidemics in the past belong to ß corona virus
  .Mild illness belonged to a,?,?
• 2002 Severe acute respiratory syndrome
  Coronavirus (SARS-CoV)
• 2012 Middle East respiratory syndrome
  Coronavirus (MERS-CoV)
• 2019 named SARS-CoV 2 as on genome sequencing
  shared 79.5 identity to SARS-CoV. use
  angiotensin-converting enzyme 2 (ACE2), the same
  receptor as SARS-CoV , to infect humans (ZhouP
  Nature 2020)
• Designated severe acute respiratory syndrome
  coronavirus 2 (SARS-CoV-2)
• Earlier referred to as 2019-nCoV.
• Viral mutations is key for explaining potential
  disease relapses
• In February 2020, the WHO designated the disease
  COVID-19, which stands for coronavirus disease
  2019

4
5
Marco CascellaFeatures evaluation and
treatment of corona virus 2020
5
6
Routes Of Transmission

• Droplets do not linger in air
• Do not travel more than 2 meters
• Also detected in blood and stools
• According to a joint WHO-China report,
  fecal-oral transmission did not appear to be a
  significant factor in the spread of infection

6
7

• LUNGS
• KIDNEY
• GI TRACT
• VASCULAR ENDOTHELIUM

2 modes of entry into respiratory epithelium
binding to ACE 2 receptors or direct fusion
Causes cell injury and release of execessive
inflammatory cytokines a s apart of normal
immune defence mechanism .This Cytokine Storm
or sustained inflammatory response leads to
extensive tissue damage, exudate production and
mucus plugging of bronchioles leading to V/Q
mismatch and pneumonia .IL-6 main cytokine
causing the storm Yan Rong Gua Military Medical
Reasearch7 2020
8
Marco CascellaFeatures evaluation and treatment
of corona virus 2020
8
9
SYMPTOMS
Marco CascellaFeatures evaluation and treatment
of corona virus 2020
9
10
Disease Severity Category

• Mild (no or mild pneumonia),
• Severe (eg, with dyspnea, hypoxia, or
• gt50 percent lung involvement on imaging within
  24 to 48 hours)
• Critical (eg, with respiratory failure, shock,
  or multiorgan dysfunction)
• Wu Z JAMA 2020, Yang X Lancet Respir
• Med 2020

10
11
Onder G JAMA 2020,Verity R Lancet Infec Dis 2020
11
12

• Risk of Infection in Pregnant
• Women
• Pregnancy does not increase the risk to contract
  the infection
• than the general population.
• But Pregnancy alters the bodys immune system and
  can cause
• more severe symptoms with COVID-19.
• This is particularly true towards the end of
  pregnancy, after 28 weeks .

13
ICMR Guidelines
Effect of COVID-19 on Pregnancy

• Pregnant women do not appear more likely to
  contract the infection than the general
  population. However, pregnancy itself alters the
  bodys immune system and response to viral
  infections in general, which can occasionally be
  related to more severe symptoms and this will be
  the same for COVID- 19.
• Reported cases of COVID-19 pneumonia in pregnancy
  are milder and with good
• recovery.
• Pregnant women with heart disease are at highest
  risk (congenital or acquired).

14
ICMR Guidelines
Effect of COVID-19 on Pregnancy

• In other types of coronavirus infection (SARS,
  MERS), the risks to the mother appear to
  increase in particular during the last trimester
  of pregnancy.
• There are case reports of preterm birth in women
  with COVID-19 but it is unclear whether the
  preterm birth was always iatrogenic, or whether
  some were spontaneous.
• The coronavirus epidemic increases the risk of
  perinatal anxiety and depression, as well as
  domestic violence. It is critically important
  that support for women and families is
  strengthened as far as possible that women are
  asked about mental health at every contact

15

• A small study of nine pregnant women in Wuhan,
  China, with confirmed COVID-19 found no evidence
  of the virus in their breast milk, cord blood or
  amniotic fluid.

16
Concluded that the subjects didnt experience
more severe pneumonia than non-pregnant patients
17

• A small retrospective study published in The
  Lancet reviewed obstetric and neonatal outcomes
  of seven pregnant women at a hospital in Wuhan
  who had contracted COVID-19 in their third
  trimesters. The outcomes for all seven women
  were good none were admitted into intensive
  care and all were discharged from the hospital.

18
Cochrane Database on COVID19 (coronavirus
disease) - Pregnancy

• According to WHO, pregnant women
• do not appear to be at higher risk of
• severe disease.
• Furthermore, WHO reports that currently there is
  no known difference between the clinical
  manifestations of COVID-19 in pregnant and non-
  pregnant women of reproductive age

19

• A (WHO) report concluded that out of 147
  pregnant women diagnosed with COVID-19, 8 had
  what the WHO classified as severe disease and
  1 were critical.
• It was determined that they werent more likely
  than non- pregnant people to develop
  life-threatening illness

20

• A study of 43 pregnancy women in New York with
  confirmed COVID-19 published in the American
  Journal of Obstetrics Gynecology in April
  found that
• unlike SARS and H1N1, pregnant women do not seem
  to experience more severe illness from the
  coronavirus compared to the general population.

21
(No Transcript)
22

• A study published as a letter in The New England
  Journal of Medicine looked at testing data from
  pregnant women who delivered between March 22
  and April 4 at New YorkPresbyterian Allen
  Hospital and Columbia University Irving Medical
  Center in New York City.
• Out of 215 patients, 88 percent of the women who
  tested
• positive for COVID-19 did not show any symptoms

23
ACOG is advising caution based on the impact of
other respiratory illnesses (including
influenza/ SARS outbreak of 20022003), stating
that pregnant women should be considered an
at-risk population for COVID-19.
24

• Precautions for all pregnant
  women
• Social distancing-at least 1 meter
• Avoid unnecessary visits outside home
• Avoid contact with people suffering from viral
  illnesses
• Practise Hand hygiene, Respiratory hygiene,
• Avoiding touching the face
• Work from home

25
ROUTINE ANC CARE IN TIMES OF COVID
25
26
Routine ANC Visits Basic Principles

• Routine Antenatal visits to be kept minimal
• Consultation on phone or video conferencing
• Come alone or keep the number of people
  accompanying to one
• Follow hand hygiene,wear masks and
  gloves,frequent hand sanitisation pre and post
  visit

27
MFM GUIDANCE FOR COVID 19
27
28
Modified ANC routine In Current scenario

• 75 gm 2hr GTT instead of 50 gmGCT
• Cell-free DNA screening (at gt10 weeks) rather
  than the combined test (ie,
• nuchal translucency on ultrasound and serum
  analytes)
• Fetal kick counts hand outs to be given
• Teleconsultation
• Home BP monitoring
• Screen for symptoms on phone . Patients who are
  symptomatic, suspected or COVID19 positive
  within the last 2 weeks.Phone Triage.
• MFM GUIDANCE FOR
• COVID 19

28
29
Suggested timing/frequency of growth
ultrasounds
in pregnancy
29
30

• Summary of common indications for antenatal
  surveillance and adjusted NST recommendations in
  setting of COVID19 pandemic
• ACOG MFM Guidance
• 2020

30
31
31
32
32
33
Indications for testing COVID 19 in
pregnancy-ICMR

• 1. A pregnant woman who has acute respiratory
  illness with one of the
• following criteria
• a history of travel abroad in the last 14 days (6
  March 2020 onwards).
• is a close contact of a laboratory proven
  positive patient or
• she is a healthcare worker herself or
• hospitalized with features of severe acute
  respiratory illness.
• 2. A pregnant woman who is presently asymptomatic
  should be tested between 5 and 14 days of coming
  into direct and high risk contact of an
  individual who has been tested positive for the
  infection.

33
34

• Rapid Tests Guidelines
• In hotpots/cluster as per MOHFW and in large
• migration gatherings/evacuees centers
• All symptomatic ILI(fever,cough,sore throat,runny
  nose)
• a.Within 7 days-rRT-PCR b.After 7 days Antibody
  test(If
• Negative,confirmed by rRT-PCR)

34
35
Test Method

• CDC recommends collection of a nasopharyngeal
  swab specimen
• Detected by reverse-transcription polymerase
  chain reaction (RT-PCR)
• Centers authorized by the government of India and
  state governments
• false negative rate of 10-30 even with two
  serial swabs
• In the near future, testing may be conducted by
  Nucleic Acid Ampli cation Test (NAAT) or by
  serological testing.
• Serology faster and cheaper stay positive even
  after 3 weeks of infection

35
36
Course of COVID 19 In Pregnancy

• Most women have mild or moderate cold/flu like
  symptoms.
• Other reported cases of COVID-19 pneumonia in
  pregnancy are milder and with good recovery
• Women with severe diseases are those who have
  associated comorbidities like DM,HT,
  BMIgt40,respiratory disease or of advanced age
• Pregnancy and Perinatal Outcomes of Women With
  Coronavirus Disease
• (COVID-19) Pneumonia A Preliminary Analysis.Liu
  D, AJR Am J Roentgenol. 2020

37
Course of COVID 19 In Pregnancy

• At present there is one published case of a woman
  with severe COVID- 19 admitted at 34 weeks, in
  the ICU with multiple organ dysfunction and
  acute respiratory distress syndrome, requiring
  extracorporeal membrane oxygenation
• Data from Australia have identified that there
  are significant increases in
• critical illness in later pregnancy, compared
  with early pregnancy
• Liu Y, . Clinical manifestations and outcome of
  SARS-CoV-2 infection
• during pregnancy. Journal of Infection 2020

38
Pregnancy complications due to COVID

• Meta analysis by Mascio D,Am J Obstet Gynecol
  MFM. 2020 41 covid positive pregnant women were
  studied

Baby

• Maternal
• preterm birth lt37 weeks (41.1 ),

• Stillbirth (2.4 )
• Admission to a NICU (10 )
• Neonatal death (2.4 )

• PPROM (18.8 ),
• preeclampsia (13.6 ),

• cesarean delivery (91.1 ),
• data reflect small numbers, related to severe
  maternal illness, women mostly intubated,may not
  directly due to fetal/neonatal infection with the
• coronavirus

39
Effect on Fetus

• Very recent evidence, suggests that the virus may
  be transmitted vertically( Dong L JAMA 2020) 3
  out of 33 neonates born to COVID positive
  mothers tested positive for corona virus
• Chen et al. found no evidence of COVID-19 in the
  amniotic fluid or cord blood of 6 infants of
  infected women(Lancet 2020)

40
Effect on Fetus

• Currently, there are inadequate data on COVID-19
  and
• risk of miscarriage or congenital anomalies or
  fetal growth restriction.
• Data from the SARS epidemic are reassuring,
  suggesting no increased risk of fetal loss or
  congenital anomalies associated with infection
  early in pregnancy
• Shek CC, Pediatrics 2003 Oct

40
41
Management of COVID 19 Positive

• As per guideline by Indian Government,COVID 19
  positive patients Based on the symptoms patient
  are divided into 3 groups mild, moderate and
  severe.
• Mild cases are shifted to government designated
  COVID CARE CENTER
• Moderate cases are shfited to Dedicated COVID
  Health Center
• Severe cases are shifted to Dedicated COVID
  Hospital

42
42
43
43
44

• ANC Care in COVID POSITIVE
• ASYMPTOMATIC PATIENT
• Routine appointments, scans / tests

• should be delayed until after the recovery
• If it is deemed that obstetric care cannot be
  delayed until after the period of isolation,
  infection prevention and control measures should
  be arranged locally to facilitate care preferably
  at the end of the working day
• If ultrasound equipment is used, this should be
  decontaminated
• after use in line with national guidance

44
45

• Management of COVID Gravid
  not in Labour
• Symptomatic
• Medical Supportive therapy rest, oxygen
  supplementation, fluid management and
  nutritional care as needed. Maternal oxygen
  saturation (SaO2) should be maintained at 95
  percent during pregnancy,
• Fetal Survellience a Bluetooth-enabled external
  fetal monitor can transmit the fetal heart rate
  tracing to the obstetric
• provider. (ACOG) MONICA NOVII WIRELESS PATCH
  SYSTEM.
• Frequency as per gestation age and patient profile

45
46

• Fever Paracetamol is the preferred drug
• Secondary bacterial infection pregnancy safe
  antibiotics

46
47
Use of medications to manage pregnancy
complications in covid positive
47
48
SPECIFIC MEDICATIONS

• Hydroxychloroquine in a dose of 600 mg (200 mg
  thrice a day with meals) and Azithromycin (500
  mg once a day) for 10 days has been shown to
  give virological cure on day 6 of treatment in
  100 of treated patients in one study( JHMI
  Clinical Guidance for Available Pharmacologic
  Therapies for COVID-19)
• Alternative dosage regimens for
  hydroxychloroquine are to give 400 mg
• twice a day on day 1 and then 400 mg once a day
  for the next four days
• Antiviral lopinavir-ritonavir (400/100 mg) twice
  daily for 14 days no difference in time to
  clinical improvement or mortality
• was seen ( Cao B 2020)

48
49

• Side effects QTc prolongation, in particular, as
• well as cardiomyopathy and retinal toxicity)
• Published clinical data on either of these
• agents are limited.

49
50
Post recovery Follow Up

• Scheduled ANC care that falls within the
  isolation period should be
• rearranged for post-isolation.
• If patient required hospitalisation for severe
  illness , ultrasound for fetal growth
  surveillance is recommended 14 days after
  resolution of acute illness.
• No evidence yet that (FGR) is a risk of COVID-19
• Two-thirds of pregnancies with SARS were affected
  by FGR and a placental abruption occurred in a
  MERS case,(Wong SF Am J Obstet Gynecol 2004

51

• LABOUR MANAGEMENT
• MFM LABOUR AND DELIVERY GUIDANCE FOR
• COVID 19 AJOG 2020

51
52
MFM LABOUR AND DELIVERY GUIDANCE FOR COVID 19

• Timing of Delivery
• In most women with non severe illness delivery
  not indicated
• In critically ill intubated pregnant woman gt32
  weeks,delivery may relieve the extra metabolic
  and pulmonary load.
• Possible benefits of this need to be weighed
  against the possible risks of worsening the
  systemic status with a surgical intervention.

52
53

• Mode Of Delivery
• Mode of birth should not be influenced by the
• presence of COVID-19,
• unless the womans respiratory condition demands
  urgent delivery.

54
Labour Triage

• A protocol should be in place in every maternity
  unit to receive pregnant women in labour or
  suspected labour with confirmed or suspected
  COVID-19 infection.
• The woman should call in advance to alert the
  maternity unit about her arrival whenever this is
  possible

54
55
Precaution for transmission prevention

• Designate rooms, or section of floor to be used
  for suspected/confirmed COVID-19 positive
  patients
• Respiratory precautions
• Room type Negative pressure room is not required
• PPE should be used
• Minimize change in providers.
• Designate one team for COVID-19 patients.

55
56
56
57

• Precaution for transmission prevention
• Birth attendants should be limited to one named
• contact
• Separate delivery room and operation theatres
• Neonatal resuscitation corners located at least 2
  m
• away from the delivery table
• Patient should wear mask during labour and
  delivery

58
Attendence in Labour

• AT first arrivalfull maternal and fetal
  assessment should be done
• Assessment of the severity of COVID-19 symptoms
  by a multidisciplinary team(Pulmonary,critical
  care team)
• Maternal observations including temperature,
  respiratory rate and oxygen saturations
• CTG-fetal surveillance
• Inform anesthetist and Neonatologist

59
Care in Labour

• Maternal vital monitoring as standard with the
  addition of hourly oxygen saturations.
• Oxygen therapy for maternal reasons only to keep
  oxygen saturation gt 94
• RCOG recommends continous electronic fetal
  monitoring
• Oxytocin augmentation is recommended to shorten
  time to delivery
• Early intervention with oxytocin and amniotomy
  for slow and dysfunctional
• labour

60
Care in Labour

• An individualised decision to shorten the second
  stage of labour with elective instrumental birth
  in a symptomatic woman who is becoming exhausted
  or hypoxic
• In case of deterioration in the womans symptoms
  assesment of risks and benefits of continuing
  the labour versus proceeding to emergency
  caesarean birth if this is likely to assist
  efforts to resuscitate the woman

61
Labour management

• All care should be taken to reduce need for blood
  transfusion
• In addition to standard oxytocin, consideration
  should be made for prophylactic tranexamic acid
  and misoprostol (400 mcg buccally)
• avoiding delayed cord clamping. RCOG recommends
  delayed clamping
• Cord blood banking can be done(ACOG)(risk of
  COVID-19 transmission by blood products has not
  been documented and is unclear at present)

62
Anesthesia Consideration

• Early epidural to minimize need for general
  anesthesia in the event of emergent cesarean
  section
• COVID-19 is not a contraindication to neuraxial
  anesthesia
• Iv analgesia should be avoided
• General anesthesia is considered an aerosolizing
  procedure, should be avoided,if not then special
  personal protective equipment should be worn.

63
Infant evaluation CDC recommendations

• Mothers with suspected COVID-19 and unknown test
  results (either pending or not tested) infants
  born to such women are not COVID- 19 suspects
• Mothers with known COVID-19 infants are COVID-19
  suspects, and they should be tested,
• isolated from other healthy infants cared for
  according to infection
• control precautions for patients with confirmed
• or suspected COVID-19

64

• Neonatal care of COVID positive patients
• No evidence of COVID-19 transmission through
  breastmilk
• However, given risk of neonatal morbidity from
  transmission through maternal exposure, CDC
  recommend separation of mother and neonate after
  discussion with mother
• Separation not required if infant tests positive
• RCOG and FOGSI recommends breast feeding with
  discussion of risk
• factors with mother

65
Breastfeeding considerations

• Breast milk provision (via pumping) is
  encouraged.
• The CDC recommends that during temporary
  separation, women who intend to breastfeed
  should be encouraged to express their breast
  milk to establish and maintain milk supply.
• Before expressing breast milk, women should
  practice appropriate hand/skin hygiene washing
  not just hands but also breast prior to pumping.

65
66

• Period of separation- AAP
• until patient is afebrile for 72 hours without
  use
• of antipyretics and
• her respiratory symptoms are improved and
• at least two consecutive SARS-CoV-2
  nasopharyngeal swab tests collected 24 hours
  apart are negative.

66
67
PRECAUTIONS WHILE BREAST FEEDING

• Wash hands before touching the baby, breast pump
  or
• bottles.
• Avoid coughing or sneezing on the baby while
  feeding.
• Consider wearing a face mask, if available, while
  feeding
• or caring for the baby.
• Where a breast pump is used, follow
  recommendations for pump cleaning after each
  use.
• Considering asking someone who is well to
• feed the baby

68
Postnatal care for COVID postive

• Continued medical evaluation for respiratory
  status and symptoms and standard practices of
  routine postnatal care
• Hygiene related to the puerperium and hand
  hygiene
• Advice on management of engorged breasts when
  feeding has not been established and measures to
  enhance breastfeeding after the isolation period
  is completed.
• Healthy, nutritious diet to recover from the
  infection and build
• immunity

69
Post partum care in Non Covid Patients IN
Current Scenario

• Expedited Discharge Planning
• All vaginal deliveries should have a goal of
  discharge on postpartum day 1, or even same day
  if possible for selected women.
• All cesarean deliveries should have a goal of
  discharge on postoperative day 2, with
  consideration of postpartum day 1 discharge if
  meeting milestones.
• Discuss anticipated maternal discharge with
  pediatrics/neonatology to determine timing of
  infant discharge.
• Home care with supplies for blood pressure follow
  up will be critical to
• expediting discharge of patients with a
  hypertensive disorder.

70

• Investigational approaches in
  treatment
• Redesmivir nucleotide analogue that has activity
  against (SARS-CoV-2) in vitro.I.V agent
  systematic evaluation of the clinical impact of
  remdesivir on COVID-19 has not yet been
  published.
• IL-6 pathway inhibitors no published clinical
  data supporting its use
• Convalescent plasma

71

• Convalescent plasma
• A case series described administration of plasma
  from donors who had completely recovered from
  COVID-19 to five patients with severe COVID-19
  on mechanical ventilation and persistently high
  viral titers despite investigational antiviral
  treatment .
• The patients had decreased nasopharyngeal viral
  load, decreased disease severity score, and
  improved oxygenation by 12 days after
  transfusion, but these findings do not establish
  a causal effect.
• Finding appropriate donors and establishing
  testing to confirm neutralizing activity of
  plasma may be logistical challenges.

• Shen C JAMA 2020

71
72
MTP/ Abortion care services RCOG

• 1.4 Priority
• Abortion care is an essential part of health
  care for women services must be maintained
  even where non-urgent or elective services are
  suspended.

72
73
MTP/ Abortion care services RCOG

• Abortion Attention

is time-sensitive. should be paid to

• providing care as early as possible given
  gestational limits.
• Organise access to abortion care
• so that delays are minimised

73
74
MTP/ Abortion care services RCOG
Suspected/ Confirmed COVID 19 If the woman
requires face-to-face assessment but the
pregnancy is likely to be under 20 weeks
gestation, care should be booked after at least
7 days since the illness started (unless she
continues to be unwell, excluding a persistent
cough).
74
75
MTP/ Abortion care services RCOG
Suspected/ Confirmed COVID 19 If the woman is
suitable for an early medical abortion at home,
she should be advised to take this approach if
she has no or mild symptoms (persistent cough is
acceptable), and before the pregnancy reaches 10
weeks gestation
75
76
MTP/ Abortion care services RCOG

• Suspected/ Confirmed COVID 19
• If the abortion cannot be safely deferred and
  face-to-face contact is necessary, request the
  woman attend at a specific time (typically end
  of clinic, in a location that is equipped to
  manage COVID-19 patients) so correct IPC
  (infection prevention and control) measures can
  be put in place. The woman should be given a
  surgical face mask to wear and asked to wash her
  hands on arrival.

76
77
MTP/ Abortion care services RCOG
Suspected/ Confirmed COVID 19 If surgical
abortion is performed Perform vacuum aspiration u
nder LA or IV sedation where feasible to avoid
need for GA Consider whether Spinal Anesthesia or
iv sedation would be more appropriate than an
anaesthetic requiring ventilation.
77
78
MTP/ Abortion care services RCOG

• Suspected/ Confirmed COVID 19
• Consider checking full blood count, clotting and
  blood group if unwell.
• Ensure that best practice is followed to reduce
  risk of transmission of infection (e.g. limit
  number of people in theatre, use PPE and
  decontaminate area after procedure as
  recommended by PHE).

78
79
MTP/ Abortion care services RCOG

• Self-isolation due to contact with suspected
  COVID-19 same practices as described for
  suspected cases to be followed

79
80
MTP/ Abortion care services RCOG

• Given that it is especially important to reduce
  contact during the COVID-19 pandemic, providing
  a second dose of 400mcg misoprostol for women
  to use 34 hours after the first if they have
  completed the abortion would seem prudent.

80
81
MTP/ Abortion care services RCOG

• There is evidence that NSAIDs (e.g. ibuprofen
  400800 mg) are effective for abortion-related
  pain, but also evidence that paracetamol is not.
• Use paracetamol in preference to ibuprofen for
  symptoms of confirmed/suspected COVID-19 but
  ibuprofen can continue to be used in other
  circumstances

81
82
MTP In Indian Context

• MTP Medication schedule H medication and cannot
  be prescribed online or on Telemedicine
• Follow all general principles of practice as per
  MTP Act
• Assessment of patient and filling of all consent
  forms is essential

82
83
MTP In Indian Context
Follow Additional Local Government Guidelines
for COVID19 as appropriate for example in Noida
it is now mandatory to test for SARSCov2 prior
to any operative procedure.
83
84
MTP In Indian Context

• In Delhi at the hospital entrance a complete
  evaluation for any influenza like illness/
  travel history / contact with suspected/
  confirmed COVID19 case /hotspot area residence
  etc is taken and then the woman is referred to
  general OPD or a separate COVID care centre
  (test not done routinely for all operative
  procedures)

84
85
Prefer Medical management If not possible
avoilaparoscopy
ECTOPIC PREGNANCY Mx in COVID 19 PANDEMIC

• proceed with minilap
• Concerns re Methotrexate as it Is a
  immunosuppresant. Is self isolation required?
• No because it is approx two one off doses in
  women who have healthy Immune systems
• Rare cases WBC count can fall so Follow up is
  must

85
86
HCW PROPHYLAXIS
86
87
87
88
88
89
89
90
(No Transcript)