Author: aau

ALL PREGNANT WOMEN WITH COVID TO BE DISCHARGED ON A MINIMUM 10 DAYS LMWH PROPHYLAXIS—CONSIDER LONGER IF OTHER RISK FACTORS

Group 1
Asymptomatic COVID positive women
(e.g. maternity phone triage)

Group 2
Symptomatic / suspected COVID positive women with
OBSTETRIC PROBLEM
(e.g. in ED with SOB/cough, OR in maternity DAU with bleeding, hyp-ertension, labour)

Maternity phone triage assessment— document COVID +ve result

Observations;
Sats >96% AND
RR<20/min

Observations;
Sats >96% on 4L/min O2
and/or
RR >24/min

IF SATS <96% on 4L/minute O2 —move to AMBER section on page 2

Obstetric problem not requiring admission
Ensure no obstetric or medical concerns
Discharge for self-isolation as per PHE guidelines

Obstetric problem requiring admission
Admit to ISOLATION room in maternity
Review by obstetric registrar
Inform Consultant Obstetrician

Obstetric problem requiring admission
Increase O2 flow fate to maintain Sats >96%
Review by medical team on call. Inform ITU team
Review by consultant obstetrician and consultant obstetric anaesthetist
If OBSTETRICALLY UNSTABLE (e.g. large bleed, severe preeclampsia, in labour) - admit to LABOUR WARD—joint care with medical and obstetric team.
If NO SERIOUS OBSTETRIC CONCERNS (e.g. mild hypertension, small bleed) - transfer to COVID MEDICAL WARD/RCU
MW care (e.g. CTG frequency) to follow normal guidance

Advise about signs and symptoms of worsening COVID –advise call 111 if worsening SOB/cough
VTE risk assessment - if HIGH give Dalteparin for 10d minimum
Midwife contact woman Day 3 and Day 10 from +ve test

Commence MEOWS chart
Prescribe:
LMWH if delivery not anticipated within 12 hours
Steroids for fetal lungs if delivery <35 weeks
MgSO4 loading dose if delivery <34 weeks

Observations recorded on MEOWS and POET
Arrange CXR +/- CTPA +/- echo
Prescribe:
Antibiotics if pneumonia
Steroids for COVID: oral prednisolone 40mg OD or IV hydrocortisone 80mg BD x 10 days
LMWH if delivery not anticipated within 12 hours (consider BD dosing)
IM Steroids for fetal lungs if delivery <35 weeks IM dex 6mg BD 4 doses THEN oral pred as above
MgSO4 loading dose if delivery <34 weeks
Consider tocilizumab. Avoid remdesivir in pregnancy unless benefit>risk
Daily review by obstetric + midwifery team while on medical ward. CTG if >26 weeks
If deteriorating resp function AND obstetrically unstable have low threshold for delivery
ANC and growth scan 2-3 weeks after discharge

This pathway does not replace clinical judgement of MEOWS score, and is not and exhaustive list for escalation, senior (consultant) decision making regarding treatment, escalation and delivery

Peri-arrest or Cardiac Arrest Call 2222 state; Maternal CARDIAC ARREST and location. Get crash trolley. Maternal AND Neonatal Crash team to attend. Consider hysterotomy to aid resuscitation

ALL PREGNANT WOMEN WITH COVID TO BE DISCHARGED ON A MINIMUM 10 DAYS LMWH PROPHYLAXIS—CONSIDER LONGER IF OTHER RISK FACTORS

Group 3
Symptomatic/ suspected COVID positive women with
NO OBSTETRIC PROBLEM
Anticipated to be in medical COVID ward (ED at admission)
Daily obstetric review
Daily CTG if >26/40

Adapted from GSTT and Kingston hospitals C19 pathway

Sats >96% on room air / RR<20	Review medical team in ED / Review by Obstetric doctor / Ensure no obstetric or medical concerns / Discharge for self isolation as per PHE guidlines	Advise about signs & symptoms of worsening COVID / Undertake a VTE risk assessment, give LMWH prophylaxis minimum 10 days—longer if other risk factors / Patient to contact maternity if any fetal/maternal concerns / Maternity team to contact woman Day 3 and Day 10 from positive test / Arrange ANC appointment in 2-3 weeks
Sats >96% on <4L/min oxygen (FiO2<28% O2) / RR<24	Increase O2 flow rate to keep sats >96% / Review medical team in ED / Review by Obstetric registrar / Inform Consultant Obstetrician and consultant obstetric anaesthetist on call / If NO obstetric concerns— admit to COVID medical ward. Joint care between Obstetrics and Medical Team / If obstetrically concern —consider admission to LW. Joint care with medical team.	Arrange CXR +/- CTPA / Consider timing of delivery / Prescribe: / Antibiotics if pneumonia / Steroids for COVID: oral prednisolone 40mg OD or IV hydrocortisone 80mg BD x 10 days (dexamethasone can be given if <12 weeks) / Steroids—for fetal lung maturity if delivery <35 weeks (Beta or Dexamethasone) / MgSO4 loading dose for fetal neuroprotection if <34 weeks if delivery / LMWH if delivery not anticipated within 12 hours (consider BD dosing) / Trial—consider recruitment to RECOVERY trial / Daily review by obstetric team. Daily CTG if >26 weeks
Sats <96% on >4L/min O2(FiO2>35%) / RR>24	Start 15L/min O2 via non-rebreath mask / Refer to ITU team and medical team / Urgent review by : consultant obstetrician and consultant obstetric anaesthetist on call / Observations on MEOWS and POET	Consider timing of delivery / Prescribe (as above) - plus MgSO4 for fetal neuroprotection <34 weeks / Consider emergency CS —if indicated for mother do not delay for fetal lung steroids / Consider nursing in prone position / Consider RECOVERY trial or experimental medication
Sats <96% on >6L/min O2 / RR>24	Urgent ITU and medical team review / Consider transfer to ITU for ?NIV/ventilation / Urgent attendance of; consultant obstetrician and consultant obstetric anaesthetist	Strongly consider delivery - emergency CS / Prescribe (as above) - plus MgSO4 for fetal neuroprotection <34 weeks / Consider nursing in prone position / Consider RECOVERY trial or experimental medication

This pathway does not replace clinical judgement of MEOWS score, and is not and exhaustive list for escalation, senior (consultant) decision making regarding treatment, escalation and delivery

Peri-arrest or Cardiac Arrest Call 2222 state; Maternal CARDIAC ARREST and location. Get crash trolley. Maternal AND Neonatal Crash team to attend. Consider hysterotomy to aid resuscitation