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Vulnerable patients: COVID-19 and pregnancy

What is the latest guidance for those who are pregnant that may be in contact with COVID-19 patients?

Unplanned learning

This article was correct at time of writing (March 23) - to keep up with the latest information please visit our coronavirus hub

As dedicated healthcare professionals at the front line of this unexpected pandemic, the most common conversation in pharmacies is identifying the vulnerable patients who are most at risk if they contract the disease. Pharmacists may have an underlying condition themselves and may have more to consider before starting their shifts in the pharmacy each day. The worry of the unknown for most pharmacists is no doubt heightened in this cohort.

Amber is a 37-year-old pharmacist with one child, aged four years, and is 20 weeks pregnant. She owns her own pharmacy, working Monday to Thursday and has two regular locums who cover the rest of the week. “I have built this business by being available and visible for my patients. I know I’ll be pausing for a few months while on maternity leave, but I can't afford to leave any earlier than I have to – my pharmacy needs me. Being pregnant is a concern, though. This is a new virus and I don’t think there is enough data on what COVID-19 could mean for me or my baby.”

What is the effect of COVID-19 on expectant mothers?

Mild or moderate flu/cold like symptoms will be experienced by most people who contract the virus. Some may experience shortness of breath, cough or fever. In severe cases, people may experience pneumonia or marked hypoxia, although these symptoms appear to be mostly observed in older patients, patients who are immunocompromised or those with underlying conditions such as cancer, diabetes or chronic lung disease. It is possible that patients could be asymptomatic or suffer only very minor symptoms – further evidence is needed to confirm this.(1)

If a pregnant person suspects they have COVID-19, they should self-isolate and call NHS 111 for advice on what to do next.

If a pregnant person suspects they may have COVID-19, or they are a confirmed case, they should not attend routine ante-natal appointments until their period of seven-day isolation is complete. They should contact their midwife to reschedule the appointment.

What is the effect of COVID-19 on the foetus?

Data does not indicate that COVID-19 increases the risk of miscarriage or early loss of pregnancy. Congenital effects of the virus on the development of the foetus appear unlikely. There have been case reports of pre-term birth in women with COVID-19 but the exact cause is unclear. There is a possible risk of foetal growth restriction, as was the case with two-thirds of pregnancies in patients affected by severe acute respiratory syndrome (SARS), although there is no available evidence for this.(1)

Should those who are pregnant continue work in the pharmacy?

It is understandable the anxiety that healthcare professionals may feel about working in a patient facing role at this uncertain time. The Royal College of Obstetricians and Gynaecologists (RCOG) has produced a detailed document on COVID-19 and considerations in pregnancy. Further guidance for pregnant healthcare workers is being sought urgently and will be published in the next RCOG update.

On March 16, pregnant women were placed into the ‘vulnerable group’ by the chief medical officer. However, the RCOG has reiterated that the latest research suggests that pregnant women are no more personally susceptible to the virus or its complications than non-pregnant people. There is, however, the possibility of risk to the foetus and the risk of premature birth if the mother should become seriously unwell as a result of the infection.

The RCOG recommend all pregnant women, regardless of gestation, should observe the social distancing guidance.

Subject to taking social distancing precautions in the work environment, in the same way as other colleagues, pregnant women under 28 weeks gestation may continue to work as normal. These pharmacists would have to consider the measures in place to restrict patient contact within the pharmacy, other pharmacy staff and the procedures followed, to limit possible infection spread, eg regular handwashing and social distancing. Pharmacists who are pregnant may feel more comfortable to reduce working hours or limit patient contact where possible.(1)

However, pregnant women from 28 weeks’ gestation (in the third trimester of pregnancy), and pregnant women with underlying health conditions, such as lung or heart disease, may experience more severe symptoms of the virus and are therefore advised to take a more precautionary approach and are strongly advised to follow social distancing advice.  Women in this category should work from home where possible, avoid contact with anyone with symptoms of COVID-19, and significantly reduce unnecessary social contact.(1

How can those who are pregnant reduce the chances of spreading the virus in the pharmacy?

Pharmacy teams may decide the limit the number of patients entering the pharmacy at any one time. Patients could be asked by another staff member before entering the pharmacy if they are suffering from any of the potential symptoms for COVID-19. These include recent onset of persistent cough, difficulty breathing and fever.

Patients displaying any of these symptoms, however mild, should be advised to stay at home for seven days from when symptoms started. Patients should not go to their GP, pharmacy or hospital and do not need to contact NHS 111 or self-test if they have symptoms. Other household members should remain home for 14 days, even if they are well, starting from the same day as the first person in the house became ill. Staying at home for 14 days will greatly reduce the overall amount of infection the household could pass on to others in the community.

Some practices that may reduce pregnant pharmacists being exposed to the virus might include avoiding long lines of patients waiting for prescriptions in the pharmacy. For example, if patients travelled by car, they may be invited to wait there until their medication is ready for collection. Pharmacists could then call the patient and ask them to come in and collect their medication, reducing time patients spend in the pharmacy. Markings on the pharmacy floor may be drawn out to show patients a safe distance to wait while queuing for medication or over the counter purchases.

Pharmacists and their team should be following recommended procedures to prevent the spread of infection, such as regular handwashing and covering their mouth and nose when coughing or sneezing.  A comprehensive list of these measures can be found on the gov.uk website, as well as information for vulnerable people including pregnant women.

Should pharmacy teams wear a face mask?

NHS England and NHS Improvement recommend that the pharmacy keeps personal protective equipment (PPE) (disposable fluid-resistant face masks, apron, disposable gloves) available in the pharmacy in case a staff member needs to enter a designated isolation space with a patient who has a COVID-19 infection or decontamination of the space is required. PPE is not required for serving customers.(2) Face masks are most effective for those who have the infection, to prevent them spreading the virus to other people – not for those who are well.(3)

What are the recommendations for breastfeeding if the mother has COVID-19?

For those who test positive for COVID-19 and are breastfeeding, the data so far suggests that the virus does not pass on to breast milk. This evidence has been established from a very small cohort of patients in China (six females) and should therefore be interpreted with caution. It is thought that there is greater risk to the infant from close contact with the mother. The RCOG advises that ‘the benefits of breastfeeding outweigh any potential risks of transmission of the virus through breastmilk’. The mother should be counselled on the potential for spread of the virus to the baby as well as the benefits of breastfeeding. For those who wish to breastfeed, the following advice from RCOG on limiting contact with the baby should be followed:

  1. Wash hands before touching the baby, breast pump or bottles.
  2. Try to avoid coughing or sneezing on the baby while feeding at the breast.
  3. Consider wearing a face mask while breastfeeding, if available.
  4. Follow recommendations for pump cleaning after each use.
  5. Consider asking someone who is well to feed expressed milk to the baby.(1)

For women bottle feeding with formula or expressed milk, strict adherence to sterilisation guidelines is recommended.(1

Other advice for those who are pregnant

For women who are well and have had no complications in any past pregnancies, the following can be advised:(1)

  • To contact their maternity unit for advice on appointments if a routine scan or visit is due in the coming weeks.
  • Those between appointments should wait to hear from their maternity team.
  • Patients should contact their maternity team if they are feeling particularly concerned. For any urgent pregnancy related problems, the maternity team should be contacted immediately.
  • Antenatal visits may be reduced, but this should be agreed with the maternity team.
Useful resources
References
  1. Royal College of Obstetricians and Gynaecologists (RCOG) (2020) Coronavirus (COVID-19) Infection in pregnancy.
  2. Pharmaceutical Services Negotiating Committee (PSNC) (2020) COVID-19: An update for community pharmacy.
  3. Australian Government Department of Health (2020) Information on the use of surgical masks.
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