Gestational surrogacy for women with recurrent pregnancy loss due to refractory chronic histiocytic intervillositis: Research Letter

Objectives: To determine clinical and laboratory features of pregnant woman with COVID-19 who require respiratory support. To recommend a management strategy that optimises maternal and fetal outcomes. Design: An observational cohort study of 7000 maternities between 1st March and 1st July 2020. Setting: Five maternity centres across a maternal medicine network in north-central London, UK Population: 69 pregnant women with confirmed acute SARS-COV2 Methods: Review of electronic healthcare records Main Outcome Measures: Clinical and laboratory features, maternal and fetal outcomes. Results: Respiratory support was needed by 15/69 . This cohort was more likely to present with dyspnoea (10/15 vs 10/54, p<0.001), a lower lymphocyte count (0.90.1 vs 1.40.1 x 109 cells/L; p<0.01) and hypokalaemia (3.80.1 vs 4.00.1 mmol/l, p<0.05). Radiological evidence of lung consolidation did not identify women in need of respiratory support. Women on respiratory support underwent childbirth at an earlier gestation than those who did not (36+4 vs 39+5 weeks, p<0.001), and required emergency c-section (6/15 vs 8/54, p<0.05). Childbirth did not improve respiratory function in those with severe disease, with 3 women remaining on invasive ventilation despite childbirth. Conclusions: Routine clinical data can identify pregnant women at risk of severe COVID-19. Pregnant women should be offered the same treatment as non-pregnant patients but iatrogenic childbirth should not be the default for women with severe disease. We propose a management pathway for pregnant women with severe COVID-19.

IntroductionThe first case of SARS-CoV2 was detected in the UK on 31st January 2020. On the 16th of March, the UK Government advised pregnant women to ‘shield’, reducing contact with others as much as possible, prior to a population-wide ‘lockdown’ commencing in the UK on 23rd March.Although many routine healthcare services in the UK were stopped or significantly reduced, maternity services have continued throughout the pandemic, with some modifications to services where feasible. This has meant that, unlike most people in the population, pregnant women in the UK have been attending hospitals and other healthcare settings throughout the pandemic for routine care rather than only for severe health issues. Therefore, pregnant women may be diagnosed with SARS-CoV2 when they attend hospital because of COVID-19 symptoms, but also may be diagnosed incidentally when they present for obstetric reasons. Increasingly, many obstetric units offer routine screening for SARS-CoV2 in all women who are admitted to hospital, with a view to identifying both symptomatic and asymptomatic patients.In our unit, swabbing for SARS-CoV2 was initially only recommended for women with symptoms suggestive of COVID-19, whether or not they attended because of those symptoms or for other obstetric reasons. These symptoms included a persistent cough or fever >37.8, with anosmia added in April 2020. From the week commencing 19th of April 2020, in line with governmental policy, increases in testing capacity enabled us to significantly increase the numbers of women tested. A pilot of surveillance screening of asymptomatic inpatients was carried out on 22nd of April, alongside commencement of routine swabbing of all women attending pre-assessment clinics for planned Caesarean section. A week later, on 29th April 2020, routine swabbing of all maternity admissions began. There are therefore two screening periods: ‘targeted’ screening prior to 19th April, and ‘enhanced’ screening after the 19th of April. Here we review the effect of these different screening strategies, in parallel with UK government advice to pregnant women, on the numbers of SARS-CoV2 cases detected within the maternity population at a large obstetric unit (approximately 7000 deliveries per year) in central London.