Coronavirus: Two pregnant NY women go undetected till after birth, expose more than 30 hospital staff to disease
Two women, who had no signs of the new coronavirus, were found to be positive after they gave birth. These two incidents in New York exposed multiple healthcare workers, at least 15 in each case, to the infection, according to US experts, who have now called for “immediate changes in obstetric clinical practice.”
The case studies have been published in a report by medical experts from New York. The team analyzed seven confirmed COVID-19 infections in pregnant women who came to a single large tertiary care center, of which the two women were asymptomatic that is, they did not show any symptoms for COVID-19 when they came to the center and when they were admitted. They did not become symptomatic until after they delivered their babies and each needed intensive care unit (ICU) admission, says the paper. The newborns have not tested positive for COVID-19 so far.
Five other pregnant women presented with symptoms of COVID-19, including cough, myalgias, fevers, chest pain and headache.
“Two of seven (28.6%) confirmed COVID-19-positive patients in this early series were asymptomatic upon admission to the obstetrical service, and these same two patients ultimately required unplanned ICU admission. Importantly, their care prior to COVID-19 diagnosis involved exposures to multiple health care workers, all of whom lacked appropriate personal protective equipment (PPE). Further, five of seven confirmed COVID-19-positive women were afebrile on the initial screen and four did not first report a cough,” say medical experts from the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, and the NewYork-Presbyterian Hospital, New York.
The researchers say that COVID-19 screening and testing protocols currently vary by institution, but in some locations where testing availability remains limited, the minimal symptoms reported for some of these cases might have been insufficient to prompt COVID-19 testing.
“It is reasonable to suspect that asymptomatic COVID-19 presentations are common and represent a substantial contribution to disease spread. Furthermore, data indicate that healthcare workers are a vulnerable population as it relates to viral transmission risk. This is undoubtedly due to their increased exposure to COVID-19 positive patients, both known and undiagnosed, as well as inadequate PPE supplies,” says the team in their findings published in the American Journal of Obstetrics & Gynecology MFM.
New York state's death toll from the coronavirus pandemic has crossed 1,000, less than a month after the first known infection in the state. As of March 29, over 142,500 cases have been reported across the US and 2,489 have died. Globally, over 34,000 have died and over 722,430 have fallen sick.
The case studies
In the first case study, a 38-year-old woman was admitted at 37 weeks’ gestation. She came with her husband and both denied symptoms of fever, cough, shortness of breath, or sore throat before admission. The initial temperature at presentation was 36.9 C. She had poorly-controlled type 2 diabetes mellitus.
Her condition deteriorated quickly after giving birth. She was tested for COVID-19 infection, which came back positive. She was discharged home on “postpartum day four with a plan for telehealth follow-up.”
An estimated 15 healthcare providers were exposed to this patient before diagnosis, including during intubation, all with inadequate personal protective equipment (PPE). After she was diagnosed with COVID-19, the patient was placed in a private room and all healthcare workers wore personal protective equipment before entering her room.
In the second case, a 33-year-old woman was admitted at 37 weeks’ gestation. She had chronic hypertension. Her medical history also included mild-intermittent asthma and type 2 diabetes mellitus. The patient also came with her husband, and both denied symptoms of fever, cough, shortness of breath, or sore throat before admission. The initial temperature was 36.5 C.
The patient underwent an uncomplicated primary cesarean delivery. The following day, approximately 25 hours after delivery, and 60 hours after labor and delivery, she developed a cough that progressed to respiratory distress.
“Following the patient’s COVID-19 diagnosis, her newborn was placed in an isolation nursery along with the infant from Case 1. Initial neonatal COVID-19 testing was negative. An estimated 15-20 healthcare providers were exposed to this patient, again without adequate PPE prior to diagnosis. After the diagnosis, the patient was cared for in private rooms and all providers donned appropriate PPE before entering,” says the report.
Healthcare personnel at major risk
According to the medical experts, obstetrical care providers are at particularly increased risk for “occupational exposure” because of long periods of interaction with patients during labor, multiple team members involved in patient care, and the “unpredictable occurrence of sudden obstetrical emergencies with their potential for unanticipated intubations in women undergoing labor and delivery.”
The researchers caution that given the risk, and in the absence of universal rapid viral testing, it must be acknowledged that every admission and delivery presents a real risk for infection to the front-line healthcare workers.
“Until adequate PPE supplies exist, we can reasonably expect our obstetrical and anesthesiology providers to become ill and exit the workforce at an accelerated rate. As of last week, 2,629 Italian health care workers (8.3% of overall cases) had experienced a COVID-19 infection, with infections attributed to inadequate equipment and asymptomatic exposures,” says the report.
It adds, ‘Without appropriate protection and rapid testing, we should expect institutions to take measures to safeguard their workforce that previously would have been inconceivable in modern society.”
Owing to the risks, the New York-Presbyterian Hospital recently announced a network-wide restriction prohibiting all visitors from attending deliveries, which implies that patients' partners will be unable to directly participate in the deliveries of their own children.
“While this policy might seem draconian, it should increase the protection of the mothers we care for, their infants, and the obstetric care team, by recognizing what series like this teach us: there is currently no easy way to clinically predict COVID-19 infection in asymptomatic people,” stresses the team.
However, the decision taken by the New York-Presbyterian Hospital may change in light of the health advisory published by the New York State Department of Health. It advises hospitals that they should allow at least one person in the delivery room.
“On March 21, 2020, the Department issued an updated guidance specific to obstetrical and pediatric settings. This health advisory replaces that guidance in order to clarify that the visitation policy requires hospitals to allow one support person in labor and delivery settings if the patient so desires and two designated support persons in pediatric settings provided that only one is present at a time,” says the advisory.
The advisory says that for labor and delivery, the Department considers one support person essential to patient care throughout labor, delivery, and the immediate postpartum period. This person can be the patient’s spouse, partner, sibling, or any other person they choose. “In these settings, this person will be the only support person allowed to be present during the patient’s care. This restriction must be explained to the patient in plain terms, upon arrival or, ideally, before arriving at the hospital. Hospital staff should ensure that patients fully understand this restriction, allowing them to decide who they wish to identify as their support person,” says the statement.
The Department further says that labor and delivery and pediatric patient support persons must be asymptomatic for COVID-19 and must not be a suspect or recently confirmed case. Additionally, hospital staff must screen the support person for symptoms of COVID-19, and conduct a temperature check before they enter the clinical area, every 12 hours thereafter and screen for potential exposures to individuals testing positive for COVID-19. The delivery person must stay in the room, and a gown, gloves and surgical mask should be given to and worn by any designated support person, says the advisory.