NIH panel releases COVID-19 treatment recommendations

 A “living document” with a comprehensive set of guidelines for treatment of COVID-19 has been released by the National Institutes of Health (NIH). Developed by a panel of physicians, statisticians and other experts, it includes recommendations for care of pregnant women.

Currently based on published and preliminary data on COVID-19 and the panelists’ own experience, the guidelines will be revised in keeping with authoritative emerging scientific reports. The key highlights from the report are that the panel: (1) doesn’t recommend use of any form of pre-exposure prophylaxis or post-exposure prophylaxis for SARS-CoV-2 outside of clinical trials; (2) recommends no additional laboratory testing or specific treatment for individuals suspected to have or confirmed to have asymptomatic or pre-symptomatic SARS-CoV-2; and (3) acknowledges lack of data on which to recommend for or against any antiviral or immunomodulatory therapy in patients with COVID-19 who have mild, moderate, severe, or critical illness.

The panel noted that individuals with mild symptoms of COVID-19 can be managed as outpatients or through telemedicine or remote visits. For moderate to severe illness, hospitalization is likely to be required. Use of airborne infection isolation rooms (AIIRs) and oxygen therapy is required for patients with severe illness, defined as SpO₂ ≤ 93% on room air at sea level, respiratory rate > 30, PaO₂/FiO₂ < 300, or lung infiltrates > 50%, as well as pulmonary imaging and laboratory tests. AAIRs also should be used for patients with COVID-19 who are critically ill.

In the section of the guidelines on considerations in patients who are pregnant or have recently delivered, the panel noted that their recommendations supplement those from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine. The same recommendations for care for non-pregnant patients generally apply to those who are pregnant. For pregnant patients who require hospitalization, care in a facility that can conduct close maternal and fetal monitoring is preferable. Fetal and uterine contraction monitoring, individualized delivery planning, and team-based case with multispecialty consultation are recommended.

For most pregnancies complicated by COVID-19, the panel said that timing of delivery should be dictated by obstetric indications. Timing of delivery need not be altered for patients who recover from COVID-19 early in pregnancy. To avoid virus transmission to the neonate, postponing delivery (barring medical indications for it) in women with COVID-19 in the third trimester is reasonable until test results for the virus are negative or quarantine restrictions are lifted. After delivery, newborns should be temporarily separated from mothers who have COVID-19 or are persons under investigation for SARS-CoV-2, to minimize the chance of transmission to via respiratory droplets. Breastfeeding is recommended by ACOG, and the Centers for Disease Control and Prevention has issued interim guidance on it in women with COVID-19.   

Dr. Brenna Hughes, MD, a maternal-fetal medicine specialist at Duke Health in Durhan, N.C., served on the panel. Her research expertise is infectious diseases in pregnancy. Dr. Hughes, along with Dr. Sarah Dotters-Katz, authored the article “COVID-19: The pathogen that will define the decade,” which appeared in the April issue of Contemporary OB/GYN.