From the frontline of COVID‐19 – how prepared are we as obstetricians? A commentary

Abstract

The World Health Organization (WHO) has declared the outbreak of novel coronavirus (2019-nCoV) — now known as Coronavirus Disease (COVID-19)1— a global health emergency. Singapore currently stands as the country with the highest number of reported cases of COVID-19 outside of China,2 excluding patients on a cruise ship offshore of Japan. It has been a week since the Ministry of Health of Singapore declared an increased alert level to DORSCON Orange using its Disease Outbreak Response System Condition (DORSCON) framework. This indicates that COVID-19 is considered a severe disease which spreads easily from person to person but which has not spread widely in Singapore and is presently being contained. This escalation in framework results in moderate disruption of daily lives through quarantine, temperature screening and hospital visitor restriction measures.3 As such, it is important for us, as obstetricians, to be vigilant and take precautionary measures as frontline healthcare workers. Currently, little is known about COVID-19 but there are valuable lessons to be learned from studies of human coronaviruses (HCoV) and the outbreak of Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) in 2003, to help guide obstetrical management during this current disease outbreak. In 2009, The Society of Obstetrics and Gynaecologists of Canada (SOGC) published its guidelines for the management of obstetric patients with suspected or probable SARS,4 after gathering information and studies from the outbreak of SARS back in 2003. This paper reviews the current literature and SOGC guidelines and shares the clinical practice recommendations and precautions taken by frontline obstetricians and healthcare workers at KK Women’s and Children’s Hospital (KKH), the largest maternity hospital in Singapore. Physiological alterations in pulmonary function during pregnancy increases the susceptibility to and severity of pneumonia.6 Earlier studies have shown that antepartum pneumonia is associated with a high perinatal mortality rate, thus aggressive treatment is required, including supportive measures with hydration, oxygen therapy and chest physiotherapy. Ng et al.7 conducted a pathophysiological evaluation of the placentas of mothers who were infected with SARS. Results from this study revealed changes in placentas that are most likely related to disruption in the maternal placental blood flow during hypoxic episodes of the acute stages of their illness. As such, one of the main aims of management of antepartum pneumonia is prevention and correction of maternal hypoxia. Currently, there is no proven anti-viral treatment available for COVID-19 patients, although anti-retroviral drugs are being therapeutically trialled on patients with severe symptoms.8 When proposing new and novel treatments, pregnant patients should be thoroughly counselled on the potential adverse effects for the patient herself as well as the teratogenic effects on her fetus. A recent study conducted by Chen et al.9 showed no evidence of intrauterine infection of COVID-19 caused by vertical transmission from mothers who developed COVID-19 pneumonia in their third trimesters. However, all nine cases studied were delivered via caesarean section and the authors were unable to analyse whether COVID-19 could be transmitted via vaginal delivery, as no vaginal mucosa samples were taken. Previous studies have shown the possibility of materno-fetal transmission of human coronavirus (HCoV)10 with evidence of the virus not only in maternal respiratory swabs but also in vaginal swabs. As such, we should aim to reduce the exposure of newborns to all maternal bodily fluids. The potential need to separate mothers with or suspected to have COVID-19 from their newborns, and therefore unable to breastfeed, may impede early bonding as well as establishment of lactation. These factors will inevitably cause additional stress for mothers in the postpartum period. In addition to caring for their physical wellbeing, medical teams should also pay more attention to the mental wellness of these mothers, providing the appropriate concern and support when needed. In response to the COVID-19 outbreak, the Division of Obstetrics and Gynaecology at KKH have established isolation (ISO) teams consisting of dedicated teams of doctors and nurses assigned to care for patients who fit the criteria for isolation at screening. This team is supported by an on call ‘clean’ team for updates, senior obstetricians and also the KKH on-site Infectious Disease physicians for advice at all hours of the day. As doctors assigned to this team, we ourselves are ‘isolated’ during our daily 12-hourly shifts to minimise contact with other patients and colleagues, with the aim to reduce the risk of exposure and potential transmission. The following outlines some impacts of isolation on different aspects of our lives. As we aim to restrict movements to minimise contact and transmission, doctors in isolation become reliant on others — from practical things such as food and drink for sustenance, to topping up of PPE and medical equipment in the isolation rooms. This comes with a sense of helplessness and guilt for having to trouble colleagues who are themselves busy during this period of stretched medical manpower. Conversely, during our lull periods, we are not able to assist our colleagues with their work to avoid contamination of ‘clean’ patients. As our knowledge of COVID-19 increases, hospital recommendations on infection control, COVID-19 screening, and isolation change rapidly in accordance with the latest evidence. As frontline doctors, we need to keep our fingers on the pulse of the latest recommendations to keep our patients, and ourselves, safe. These extended working hours also inevitably mean less time for usual activities outside of work such as family, friends, and general wellbeing. Although we keep ourselves busy during our shifts, the prolonged duration of isolation increases stress levels, restlessness, and physical inactivity as we are confined to a small physical area. Lack of exercise affects both our physical and mental health;12 exercise has been shown to reduce anxiety, depression and negative mood and to improve self-esteem and cognitive function, all characteristics important for maintaining resilience during this disease outbreak. We were informed only a few hours after the declaration of DORSCON Orange in Singapore that we would be part of the first ISO team. This has been followed by feelings of anxiety and stress as we face many uncertainties, and the growing fear that with the rising number of cases of COVID-19, each patient we see presents a greater risk to our personal health and that of the people around us. But tere is the relief that comes with each negative swab result as we continue our duties as the ISO team for this uncertain but seemingly dangerous infection. Our families and the Singapore general public have been incredibly supportive during this difficult period, with volunteers providing travel services and corporations providing free food to healthcare workers. Our gratitude is unspoken; we keep our distance in the hope of keeping them safe. We are certainly not alone in these thoughts and plan to study formally the wellbeing of our colleagues who serve on current and future ISO teams. Meanwhile, it is imperative to remind all healthcare workers of the importance of self-protection, hand hygiene and self-care as we continue in our mission to care for patients who are at the heart of all that we do. None. There was no financial support. Completed disclosure of interests forms are available to view online as supporting information. MSQC: Preparation, manuscript original writing. JCSL, SS, and HKT: Conceptualisation, supervision, manuscript review and edit. No ethics approval applicable for this commentary. There was no financial support for this commentary. The authors would like to acknowledge the valuable input from Dr Ni Ni Soe, staff registrar and fellow isolation team member, Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.