No. 225-Management Guidelines for Obstetric Patients and Neonates Born to Mothers With Suspected or Probable Severe Acute Respiratory Syndrome (SARS)
Identifieur interne : 000B71 ( Pmc/Corpus ); précédent : 000B70; suivant : 000B72No. 225-Management Guidelines for Obstetric Patients and Neonates Born to Mothers With Suspected or Probable Severe Acute Respiratory Syndrome (SARS)
Auteurs : Cynthia MaxwellSource :
- Journal of Obstetrics and Gynaecology Canada [ 1701-2163 ] ; 2017.
Abstract
This document summarizes the limited experience of SARS in pregnancy and suggests guidelines for management.
Cases reported from Asia suggest that maternal and fetal outcomes are worsened by SARS during pregnancy.
Medline was searched for relevant articles published in English from 2000 to 2007. Case reports were reviewed and expert opinion sought.
Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.
The Society of Obstetricians and Gynaecologists of Canada.
All hospitals should have infection control systems in place to ensure that alerts regarding changes in exposure risk factors for SARS or other potentially serious communicable diseases are conveyed promptly to clinical units, including the labour and delivery unit (III-C). At times of SARS outbreaks, all pregnant patients being assessed or admitted to the hospital should be screened for symptoms of and risk factors for SARS (III-C). Upon arrival in the labour triage unit, pregnant patients with suspected and probable SARS should be placed in a negative pressure isolation room with at least 6 air exchanges per hour. All labour and delivery units caring for suspected and probable SARS should have available at least one room in which patients can safely labour and deliver while in need of airborne isolation (III-C). If possible, labour and delivery (including operative delivery or Caesarean section) should be managed in a designated negative pressure isolation room, by designated personnel with specialized infection control preparation and protective gear (III-C). Either regional or general anaesthesia may be appropriate for delivery of patients with SARS (III-C). Neonates of mothers with SARS should be isolated in a designated unit until the infant has been well for 10 days, or until the mother’s period of isolation is complete. The mother should not breastfeed during this period (III-C). A multidisciplinary team, consisting of obstetricians, nurses, pediatricians, infection control specialists, respiratory therapists, and anaesthesiologists, should be identified in each unit and be responsible for the unit organization and implementation of SARS management protocols (III-C). Staff caring for pregnant SARS patients should not care for other pregnant patients. Staff caring for pregnant SARS patients should be actively monitored for fever and other symptoms of SARS. Such individuals should not work in the presence of any SARS symptoms within 10 days of exposure to a SARS patient (III-C). All health care personnel, trainees, and support staff should be trained in infection control management and containment to prevent spread of the SARS virus (III-A). Regional health authorities in conjunction with hospital staff should consider designating specific facilities or health care units, including primary, secondary, or tertiary health care centres, to care for patients with SARS or similar illnesses (III-A).
Url:
DOI: 10.1016/j.jogc.2017.04.024
PubMed: 28729104
PubMed Central: 7105038
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PMC:7105038Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">No. 225-Management Guidelines for Obstetric Patients and Neonates Born to Mothers With Suspected or Probable Severe Acute Respiratory Syndrome (SARS)</title><author><name sortKey="Maxwell, Cynthia" sort="Maxwell, Cynthia" uniqKey="Maxwell C" first="Cynthia" last="Maxwell">Cynthia Maxwell</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28729104</idno><idno type="pmc">7105038</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7105038</idno><idno type="RBID">PMC:7105038</idno><idno type="doi">10.1016/j.jogc.2017.04.024</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">000B71</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000B71</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">No. 225-Management Guidelines for Obstetric Patients and Neonates Born to Mothers With Suspected or Probable Severe Acute Respiratory Syndrome (SARS)</title><author><name sortKey="Maxwell, Cynthia" sort="Maxwell, Cynthia" uniqKey="Maxwell C" first="Cynthia" last="Maxwell">Cynthia Maxwell</name></author></analytic><series><title level="j">Journal of Obstetrics and Gynaecology Canada</title><idno type="ISSN">1701-2163</idno><idno type="eISSN">1701-2163</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Objective</title><p>This document summarizes the limited experience of SARS in pregnancy and suggests guidelines for management.</p></sec><sec><title>Outcomes</title><p>Cases reported from Asia suggest that maternal and fetal outcomes are worsened by SARS during pregnancy.</p></sec><sec><title>Evidence</title><p>Medline was searched for relevant articles published in English from 2000 to 2007. Case reports were reviewed and expert opinion sought.</p></sec><sec><title>Values</title><p>Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.</p></sec><sec><title>Sponsors</title><p>The Society of Obstetricians and Gynaecologists of Canada.</p></sec><sec><title>Recommendations</title><p><list list-type="simple" id="olist0010"><list-item id="o0010"><label>1.</label><p id="p0010">All hospitals should have infection control systems in place to ensure that alerts regarding changes in exposure risk factors for SARS or other potentially serious communicable diseases are conveyed promptly to clinical units, including the labour and delivery unit (III-C).</p></list-item><list-item id="o0015"><label>2.</label><p id="p0015">At times of SARS outbreaks, all pregnant patients being assessed or admitted to the hospital should be screened for symptoms of and risk factors for SARS (III-C).</p></list-item><list-item id="o0020"><label>3.</label><p id="p0020">Upon arrival in the labour triage unit, pregnant patients with suspected and probable SARS should be placed in a negative pressure isolation room with at least 6 air exchanges per hour. All labour and delivery units caring for suspected and probable SARS should have available at least one room in which patients can safely labour and deliver while in need of airborne isolation (III-C).</p></list-item><list-item id="o0025"><label>4.</label><p id="p0025">If possible, labour and delivery (including operative delivery or Caesarean section) should be managed in a designated negative pressure isolation room, by designated personnel with specialized infection control preparation and protective gear (III-C).</p></list-item><list-item id="o0030"><label>5.</label><p id="p0030">Either regional or general anaesthesia may be appropriate for delivery of patients with SARS (III-C).</p></list-item><list-item id="o0035"><label>6.</label><p id="p0035">Neonates of mothers with SARS should be isolated in a designated unit until the infant has been well for 10 days, or until the mother’s period of isolation is complete. The mother should not breastfeed during this period (III-C).</p></list-item><list-item id="o0040"><label>7.</label><p id="p0040">A multidisciplinary team, consisting of obstetricians, nurses, pediatricians, infection control specialists, respiratory therapists, and anaesthesiologists, should be identified in each unit and be responsible for the unit organization and implementation of SARS management protocols (III-C).</p></list-item><list-item id="o0045"><label>8.</label><p id="p0045">Staff caring for pregnant SARS patients should not care for other pregnant patients. Staff caring for pregnant SARS patients should be actively monitored for fever and other symptoms of SARS. Such individuals should not work in the presence of any SARS symptoms within 10 days of exposure to a SARS patient (III-C).</p></list-item><list-item id="o0050"><label>9.</label><p id="p0050">All health care personnel, trainees, and support staff should be trained in infection control management and containment to prevent spread of the SARS virus (III-A).</p></list-item><list-item id="o0055"><label>10.</label><p id="p0055">Regional health authorities in conjunction with hospital staff should consider designating specific facilities or health care units, including primary, secondary, or tertiary health care centres, to care for patients with SARS or similar illnesses (III-A).</p></list-item></list></p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Ksiazek, T J" uniqKey="Ksiazek T">T.J. Ksiazek</name></author><author><name sortKey="Erdman, T" uniqKey="Erdman T">T. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Obstet Gynaecol Can</journal-id><journal-id journal-id-type="iso-abbrev">J Obstet Gynaecol Can</journal-id><journal-title-group><journal-title>Journal of Obstetrics and Gynaecology Canada</journal-title></journal-title-group><issn pub-type="ppub">1701-2163</issn><issn pub-type="epub">1701-2163</issn><publisher><publisher-name>Published by Elsevier Inc. on behalf of The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28729104</article-id><article-id pub-id-type="pmc">7105038</article-id><article-id pub-id-type="publisher-id">S1701-2163(17)30464-4</article-id><article-id pub-id-type="doi">10.1016/j.jogc.2017.04.024</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>No. 225-Management Guidelines for Obstetric Patients and Neonates Born to Mothers With Suspected or Probable Severe Acute Respiratory Syndrome (SARS)</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Maxwell</surname><given-names>Cynthia</given-names></name><degrees>MD</degrees><email>CynthiaDr.Maxwell@sinaihealthsystem.ca</email><xref rid="cor1" ref-type="corresp">∗</xref></contrib></contrib-group><aff id="aff1">Toronto, ON</aff><contrib-group><contrib contrib-type="author" id="au2"><name><surname>McGeer</surname><given-names>Alison</given-names></name><degrees>MD</degrees></contrib></contrib-group><aff id="aff2">Toronto, ON</aff><contrib-group><contrib contrib-type="author" id="au3"><name><surname>Tai</surname><given-names>Kin Fan Young</given-names></name><degrees>MD</degrees></contrib></contrib-group><aff id="aff3">Toronto, ON</aff><contrib-group><contrib contrib-type="author" id="au4"><name><surname>Sermer</surname><given-names>Mathew</given-names></name><degrees>MD</degrees></contrib></contrib-group><aff id="aff4">Toronto, ON</aff><author-notes><corresp id="cor1"><label>∗</label>Corresponding Author: Dr. Cynthia Maxwell, University of Toronto, Toronto, ON. <email>CynthiaDr.Maxwell@sinaihealthsystem.ca</email></corresp><fn id="fn1"><label>∗</label><p id="ntpara012010">Maternal Fetal Medicine Committee: Dan Farine (Chair), MD, Toronto, ON; Melanie Basso, RN, Vancouver, BC; Marie-France Delisle, MD, Vancouver, BC; Lynda Hudon, MD, Montréal, QC; Savas Menticoglou, MD, Winnipeg, MB; William Mundle, MD, Windsor, ON; Annie Ouellet, MD, Sherbrooke, QC. Infectious Disease Committee: Mark H. Yudin (Chair), MD, Toronto, ON; Marc Boucher, MD, Montréal, QC; Eliana Castillo, MD, Vancouver, BC; Beatrice Cormier, MD, Montréal, QC; Andrée Gruslin, MD, Ottawa, ON; Deborah M. Money, MD, Vancouver, BC; Kellie Murphy, MD, Toronto, ON; Caroline Paquet, RM, Trois-Rivières, QC; Audrey Steenbeek, RN, Halifax, NS; Nancy Van Eyk, MD, Halifax, NS; Julie van Schalkwyk, MD, Vancouver, BC; Thomas Wong, MD, Ottawa, ON. Disclosure statements have been received from all members of the committees.</p></fn></author-notes><pub-date pub-type="pmc-release"><day>18</day><month>7</month><year>2017</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub"><month>8</month><year>2017</year></pub-date><pub-date pub-type="epub"><day>18</day><month>7</month><year>2017</year></pub-date><volume>39</volume><issue>8</issue><fpage>e130</fpage><lpage>e137</lpage><permissions><copyright-statement>© 2017 Published by Elsevier Inc. on behalf of The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada.</copyright-statement><copyright-year>2017</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><sec><title>Objective</title><p>This document summarizes the limited experience of SARS in pregnancy and suggests guidelines for management.</p></sec><sec><title>Outcomes</title><p>Cases reported from Asia suggest that maternal and fetal outcomes are worsened by SARS during pregnancy.</p></sec><sec><title>Evidence</title><p>Medline was searched for relevant articles published in English from 2000 to 2007. Case reports were reviewed and expert opinion sought.</p></sec><sec><title>Values</title><p>Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.</p></sec><sec><title>Sponsors</title><p>The Society of Obstetricians and Gynaecologists of Canada.</p></sec><sec><title>Recommendations</title><p><list list-type="simple" id="olist0010"><list-item id="o0010"><label>1.</label><p id="p0010">All hospitals should have infection control systems in place to ensure that alerts regarding changes in exposure risk factors for SARS or other potentially serious communicable diseases are conveyed promptly to clinical units, including the labour and delivery unit (III-C).</p></list-item><list-item id="o0015"><label>2.</label><p id="p0015">At times of SARS outbreaks, all pregnant patients being assessed or admitted to the hospital should be screened for symptoms of and risk factors for SARS (III-C).</p></list-item><list-item id="o0020"><label>3.</label><p id="p0020">Upon arrival in the labour triage unit, pregnant patients with suspected and probable SARS should be placed in a negative pressure isolation room with at least 6 air exchanges per hour. All labour and delivery units caring for suspected and probable SARS should have available at least one room in which patients can safely labour and deliver while in need of airborne isolation (III-C).</p></list-item><list-item id="o0025"><label>4.</label><p id="p0025">If possible, labour and delivery (including operative delivery or Caesarean section) should be managed in a designated negative pressure isolation room, by designated personnel with specialized infection control preparation and protective gear (III-C).</p></list-item><list-item id="o0030"><label>5.</label><p id="p0030">Either regional or general anaesthesia may be appropriate for delivery of patients with SARS (III-C).</p></list-item><list-item id="o0035"><label>6.</label><p id="p0035">Neonates of mothers with SARS should be isolated in a designated unit until the infant has been well for 10 days, or until the mother’s period of isolation is complete. The mother should not breastfeed during this period (III-C).</p></list-item><list-item id="o0040"><label>7.</label><p id="p0040">A multidisciplinary team, consisting of obstetricians, nurses, pediatricians, infection control specialists, respiratory therapists, and anaesthesiologists, should be identified in each unit and be responsible for the unit organization and implementation of SARS management protocols (III-C).</p></list-item><list-item id="o0045"><label>8.</label><p id="p0045">Staff caring for pregnant SARS patients should not care for other pregnant patients. Staff caring for pregnant SARS patients should be actively monitored for fever and other symptoms of SARS. Such individuals should not work in the presence of any SARS symptoms within 10 days of exposure to a SARS patient (III-C).</p></list-item><list-item id="o0050"><label>9.</label><p id="p0050">All health care personnel, trainees, and support staff should be trained in infection control management and containment to prevent spread of the SARS virus (III-A).</p></list-item><list-item id="o0055"><label>10.</label><p id="p0055">Regional health authorities in conjunction with hospital staff should consider designating specific facilities or health care units, including primary, secondary, or tertiary health care centres, to care for patients with SARS or similar illnesses (III-A).</p></list-item></list></p></sec></abstract><kwd-group id="kwrds0010"><title>Key Words</title><kwd>Severe acute respiratory syndrome (SARS)</kwd><kwd>pregnancy</kwd><kwd>perinatal morbidity</kwd><kwd>perinatal mortality</kwd><kwd>maternal morbidity</kwd><kwd>maternal mortality</kwd><kwd>acute respiratory distress syndrome (ARDS)</kwd><kwd>neonatal care</kwd></kwd-group></article-meta><notes><p id="misc0010">No. 225, August 2017</p></notes></front><body><sec id="sec3"><title>Introduction</title><p id="p0155"><boxed-text id="dtbox1"><p id="p0160">This document reflects emerging clinical and scientific advances on the date issued, and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.</p><p id="p0165">Women have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice women should be provided with information and support that is evidence based, culturally appropriate and tailored to their needs. The values, beliefs and individual needs of each woman and her family should be sought and the final decision about the care and treatment options chosen by the woman should be respected.</p></boxed-text></p><p id="p0170">Severe acute respiratory syndrome, or SARS, emerged as a highly contagious and life-threatening condition in 2003. By the end of 2003, a total of 8096 cases had been identified internationally, and 774 deaths were reported.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> Although the majority of cases occurred in South East Asia, 251 probable cases, 187 suspected cases, and 43 deaths were reported in Canada as of September 2003.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> It is now known that SARS is caused by a novel coronavirus<xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref> and is easily spread by respiratory droplets and nosocomial contact.<xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib7" ref-type="bibr">7</xref> Evidence suggests that health care facilities are the major source for new SARS infections; this was a major factor in the so-called “second wave” of SARS infections in April and May 2003 in the Greater Toronto Area. During this period, affected patients from outlying areas were transferred to a designated tertiary care hospital for treatment in order to limit the number of institutions with active SARS cases. Fortunately, only one case of SARS occurring in pregnancy was reported in Canada.<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref><table-wrap position="float" id="tbl1"><label>Table</label><caption><p>Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventive Health Care</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Quality of Evidence Assessment<xref rid="tbl1fna" ref-type="table-fn">a</xref></th><th>Classification of Recommendations<xref rid="tbl1fnb" ref-type="table-fn">b</xref></th></tr></thead><tbody><tr><td><list list-type="simple" id="olist0020"><list-item id="o0110"><label>I:</label><p id="p0615">Evidence obtained from at least one properly randomized controlled trial.</p></list-item><list-item id="o0115"><label>II-1:</label><p id="p0620">Evidence from well-designed controlled trials without randomization.</p></list-item><list-item id="o0120"><label>II-2:</label><p id="p0625">Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group.</p></list-item><list-item id="o0125"><label>II-3:</label><p id="p0630">Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.</p></list-item><list-item id="o0130"><label>III:</label><p id="p0635">Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.</p></list-item></list></td><td><list list-type="simple" id="olist0025"><list-item id="o0135"><label>A.</label><p id="p0640">There is good evidence to recommend the clinical preventive action.</p></list-item><list-item id="o0140"><label>B.</label><p id="p0645">There is fair evidence to recommend the clinical preventive action.</p></list-item><list-item id="o0145"><label>C.</label><p id="p0650">The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.</p></list-item><list-item id="o0150"><label>D.</label><p id="p0655">There is fair evidence to recommend against the clinical preventive action.</p></list-item><list-item id="o0155"><label>E.</label><p id="p0660">There is good evidence to recommend against the clinical preventive action.</p></list-item><list-item id="o0160"><label>L.</label><p id="p0665">There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.</p></list-item></list></td></tr></tbody></table><table-wrap-foot><fn id="tbl1fna"><label>a</label><p id="ntpara0025">The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.<xref rid="bib40" ref-type="bibr"><sup>40</sup></xref></p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl1fnb"><label>b</label><p id="ntpara0030">Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the The Canadian Task Force on Preventive Health Care.<xref rid="bib40" ref-type="bibr"><sup>40</sup></xref></p></fn></table-wrap-foot></table-wrap></p><p id="p0185">This document summarizes the limited information available regarding SARS in pregnancy and suggests strategies for managing pregnant women and their families in the antenatal, labour and delivery, and postnatal settings. The approach and recommendation of this document may be helpful in creating protocols for other new airborne viral infections.</p></sec><sec id="sec4"><title>History of the SARS Epidemic</title><p id="p0190">In February 2003, the first cases of SARS in Canada, presenting as an atypical pneumonia, occurred in the Toronto area. All cases that subsequently occurred in the region can be traced to one of the individuals first affected.<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref> Similar outbreaks were reported in Hong Kong,<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> Vietnam,<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref> Singapore,<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> Thailand,<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> and Taiwan.<xref rid="bib13" ref-type="bibr"><sup>13</sup></xref> The diagnosis of SARS was based on viral testing in combination with several clinical findings.<xref rid="bib1" ref-type="bibr">1</xref>, <xref rid="bib14" ref-type="bibr">14</xref></p></sec><sec id="sec5"><title>Treatment and Prevention Strategies</title><p id="p0195">Health Canada has outlined the following basic principles for management and treatment of SARS in non-pregnant individuals, as well as recommended testing for SARS.<xref rid="bib14" ref-type="bibr"><sup>14</sup></xref></p><sec id="sec5.1"><title>Clinical Features, Treatment and Outcome in Non-Pregnant SARS Patients</title><p id="p0200">In a study of 144 patients with SARS from the Greater Toronto Area, most patients were exposed in the hospital setting (77%).<xref rid="bib15" ref-type="bibr"><sup>15</sup></xref> These individuals included health care workers, patients, and visitors to the hospital. The median time from self-reported exposure to onset of symptoms was 6 to 9 days. Almost all patients received empirical antibiotic therapy (95%) and ribavirin (88%). Forty percent of patients received steroids.</p><p id="p0205">Of the 20% of patients admitted to the intensive care unit (ICU), 69% required mechanical ventilation. There were 8 deaths, or a 6.5% mortality rate. Predictors of poor outcome (death or admission to the ICU) included increased age, male sex, diabetes, increased neutrophil count, creatine kinase, and urea. In a separate study assessing the outcomes of critically ill patients with SARS in the Toronto area, investigators found that 76% required mechanical ventilation.<xref rid="bib16" ref-type="bibr"><sup>16</sup></xref> Among those requiring ventilation, the mortality rate was 45%. In this study, transmission of SARS within 6 of the intensive care units that were evaluated prompted closure of 73 medical-surgical ICU beds, leading to 164 health care workers being placed in quarantine.</p></sec><sec id="sec5.2"><title>Effects of SARS in Pregnancy</title><sec id="sec5.2.1"><title>Pulmonary infections in pregnancy</title><p id="p0210">The most common non-obstetric infection during pregnancy is pneumonia,<xref rid="bib17" ref-type="bibr">17</xref>, <xref rid="bib18" ref-type="bibr">18</xref>, <xref rid="bib19" ref-type="bibr">19</xref> and in a series of studies, it is the third most common cause of indirect obstetric death.<xref rid="bib20" ref-type="bibr"><sup>20</sup></xref> In the pre-antibiotic era, maternal mortality was as high as 30%<xref rid="bib21" ref-type="bibr"><sup>21</sup></xref>; more recently, it is reported to be less than 10%.<xref rid="bib18" ref-type="bibr">18</xref>, <xref rid="bib19" ref-type="bibr">19</xref> Nonetheless, approximately 25% of pregnant patients with pneumonia will require ventilatory support in a critical care unit.<xref rid="bib18" ref-type="bibr"><sup>18</sup></xref> Viral pneumonia is associated with higher morbidity and mortality than bacterial pneumonia responsive to antibiotics.<xref rid="bib22" ref-type="bibr"><sup>22</sup></xref> Physiologic changes in pregnancy, including altered cell-mediated immunity<xref rid="bib23" ref-type="bibr"><sup>23</sup></xref> and alterations in pulmonary function,<xref rid="bib24" ref-type="bibr">24</xref>, <xref rid="bib25" ref-type="bibr">25</xref>, <xref rid="bib26" ref-type="bibr">26</xref> are hypothesized to affect the susceptibility to and severity of pneumonia.</p><p id="p0220">The most detailed reports of viral pneumonia are of cases caused by influenza or varicella.</p><p id="p0225">The influenza epidemic of 1918 had a maternal mortality rate of 30% to 50%.<xref rid="bib27" ref-type="bibr">27</xref>, <xref rid="bib28" ref-type="bibr">28</xref> During the 1957–1958 Asian flu epidemic, the maternal mortality rate was twice that of non-pregnant women, with a higher rate in the third trimester.<xref rid="bib29" ref-type="bibr"><sup>29</sup></xref> Ten percent of all deaths related to this influenza epidemic were in pregnant women.<xref rid="bib27" ref-type="bibr"><sup>27</sup></xref></p><p id="p0230">The most common fetal complications arising from maternal pneumonia include prematurity resulting from preterm labour (up to 44%), intrauterine growth restriction (up to 12%), intrauterine demise (up to 3%), and neonatal demise (up to 12%).<xref rid="bib17" ref-type="bibr">17</xref>, <xref rid="bib18" ref-type="bibr">18</xref>, <xref rid="bib19" ref-type="bibr">19</xref> Furthermore, mid-trimester exposure to certain viruses (such as varicella) may cause embryopathy and multiple congenital anomalies.<xref rid="bib30" ref-type="bibr">30</xref>, <xref rid="bib31" ref-type="bibr">31</xref></p></sec></sec><sec id="sec5.3"><title>SARS Cases Reported in Pregnancy</title><p id="p0235">By May 2003, a total of 10 cases of SARS had been reported in pregnant patients from Hong Kong.<xref rid="bib32" ref-type="bibr"><sup>32</sup></xref> Hypoxia, resulting from SARS-related acute respiratory distress syndrome, led to early pregnancy loss in 4 of the 10 cases. To help protect the fetus, pregnant women were given supplemental oxygen to maintain maternal arterial saturation above 95%, and kept in an upright position. Women receiving mechanical ventilation were maintained in the left lateral position to maximize uterine blood flow. Fetal status was monitored using cardiotocography, and ultrasound examination was used to monitor growth and Doppler flows.</p><p id="p0240">All pregnant patients were treated empirically with broad-spectrum antibiotics (e.g., clarithromycin, amoxicillin-clavulanate) to prevent secondary bacterial infections. Ribavirin was reserved for patients with the most severe forms of the illness. As there is no evidence for ribavirin being effective in treating SARS, it is currently not recommended.<xref rid="bib14" ref-type="bibr"><sup>14</sup></xref> High dose pulse corticosteroids were administered in several cases.<xref rid="bib33" ref-type="bibr"><sup>33</sup></xref> Two deaths occurred in pregnant patients receiving high dose steroids in association with multi-drug resistant Staphylococcus aureus (MRSA) septicemia. The pregnant women thought to be at risk for preterm birth were given additional dexamethasone as prophylaxis for the fetus.</p><p id="p0245">Pregnant patients with SARS were isolated from other antenatal and postnatal patients. A small core group of personnel were assigned to care for these patients exclusively, and all used strict respiratory precautions (such as the use of N95 masks or the equivalent), special gowns, and negative air pressure circulation at all times.</p><p id="p0250">The outcomes in pregnant SARS patients in Hong Kong appeared to be worse than outcomes in their non-pregnant counterparts. Of the seven cases followed at the designated SARS unit, two died (28%), and four (57%) were admitted to intensive care for mechanical ventilation. This is in contrast to mortality rates of less than 10% and mechanical ventilation rates of less than 20% in non-pregnant, age-matched counterparts. Fortunately, there was no clinical or laboratory evidence of SARS in any of the babies delivered in this series.</p><p id="p0255">No conclusions could be drawn about the safety of planned early delivery by the vaginal route compared with Caesarean delivery, or regional anaesthesia compared with general anaesthesia. However, for the most severe cases, Caesarean delivery and general endotracheal anaesthesia were elected in order to avoid emergency airway issues and to minimize exposure risk for others. As with mothers infected with HIV, SARS-affected patients were advised against breastfeeding in case of possible vertical transmission of the virus.</p></sec><sec id="sec5.4"><title>Antivirals Used to Treat SARS in Pregnancy</title><p id="p0260">There is no evidence that ribavirin is effective in the treatment of coronaviruses or SARS.<xref rid="bib15" ref-type="bibr">15</xref>, <xref rid="bib34" ref-type="bibr">34</xref>, <xref rid="bib35" ref-type="bibr">35</xref> Furthermore, there is evidence of severe toxicity in SARS patients as a result of treatment with ribavirin.<xref rid="bib36" ref-type="bibr"><sup>36</sup></xref> In Canada, ribavirin is no longer recommended for treatment of SARS.<xref rid="bib14" ref-type="bibr"><sup>14</sup></xref></p><p id="p0265">In vitro evidence suggests a role for the use of human recombinant interferons α, β, and γ in the treatment of SARS.<xref rid="bib37" ref-type="bibr">37</xref>, <xref rid="bib38" ref-type="bibr">38</xref> Their use in the clinical setting of SARS in pregnancy requires further investigation.</p></sec><sec id="sec5.5"><title>Institutional and Personnel Issues in the Care of Pregnant SARS Patients</title><p id="p0270">A review of the Hong Kong experience provides important information. For example, all pregnant patients with SARS were managed in one unit at a designated maternity hospital. At one institution with a referral-based obstetrics and gynaecology service, the administration coordinated a transfer arrangement of SARS patients to the designated SARS hospital.<xref rid="bib39" ref-type="bibr"><sup>39</sup></xref> All non-urgent ambulatory and elective gynaecological/surgical services were suspended.</p><p id="p0275">The overall number of staff was limited, and only a specific subgroup was assigned to the care of SARS pregnant patients. Communications among medical personnel were by phone or by electronic mail, and teaching conferences were suspended. Clinical teaching was limited to avoid unnecessary exposures. Infection control teaching modules were developed for all obstetrical staff, and all workers were routinely screened for symptoms and signs of infection.</p></sec><sec id="sec5.6"><title>Suggested Management Guidelines for Pregnant Women With Confirmed SARS</title><sec id="sec5.6.1"><title>Labour triage and antenatal hospital admission</title><sec id="sec5.6.1.1"><title>Actions</title><p id="p0280"><list list-type="simple" id="ulist0010"><list-item id="u0010"><label>•</label><p id="p0285">Assessment is made as to whether the patient has suspected or probable SARS<xref rid="bib1" ref-type="bibr">1</xref>, <xref rid="bib14" ref-type="bibr">14</xref></p></list-item><list-item id="u0015"><label>•</label><p id="p0290">Upon arrival in the labour and delivery triage unit, pregnant patients presenting with fever >38°C and respiratory symptoms and one of the associated symptoms (cough, unexplained hypoxia, shortness of breath, or dyspnea) and history of an exposure to an individual with probable SARS are immediately transferred to the designated isolation room, which is equipped with negative pressure ventilation. This may be a SARS unit in the case of epidemic exposures. If necessary, procedures and delivery may be performed in this isolation room</p></list-item><list-item id="u0020"><label>•</label><p id="p0295">A detailed travel and contact history is obtained from the patient</p></list-item><list-item id="u0025"><label>•</label><p id="p0300">All staff and visitors should wear the following protective items before entry to the room:<list list-type="simple" id="ulist0015"><list-item id="u0030"><label>-</label><p id="p0305">Gown</p></list-item><list-item id="u0035"><label>-</label><p id="p0310">N 95 mask</p></list-item><list-item id="u0040"><label>-</label><p id="p0315">Eye protection</p></list-item><list-item id="u0045"><label>-</label><p id="p0320">Gloves</p></list-item></list></p></list-item></list></p></sec><sec id="sec5.6.1.2"><title>Communications</title><p id="p0325"><list list-type="simple" id="ulist0020"><list-item id="u0050"><label>•</label><p id="p0330">Obstetrical staff, infection control and public health authorities are notified immediately</p></list-item><list-item id="u0055"><label>•</label><p id="p0335">Counselling of the pregnant patient should include discussions regarding<list list-type="simple" id="ulist0025"><list-item id="u0060"><label>-</label><p id="p0340">possible fetal effects of SARS viremia</p></list-item><list-item id="u0065"><label>-</label><p id="p0345">possible fetal risks of maternal respiratory failure</p></list-item><list-item id="u0070"><label>-</label><p id="p0350">obstetrical management at <24 weeks’ gestation, including option of termination of pregnancy</p></list-item><list-item id="u0075"><label>-</label><p id="p0355">obstetrical management at 24–34 weeks’ gestation, including discussion of β–methasone administration, mode of delivery, type of anaesthesia, use of intravenous antibiotics and corticosteroids, possible perimortem Caesarean delivery in the setting of maternal demise</p></list-item><list-item id="u0080"><label>-</label><p id="p0360">obstetrical management at >34 weeks’ gestation, including discussion of mode of delivery, type of anaesthesia, use of intravenous antibiotics and corticosteroids, possible perimortem Caesarean delivery in the setting of maternal demise</p></list-item></list></p></list-item></list></p></sec></sec><sec id="sec5.6.2"><title>Delivery</title><sec id="sec5.6.2.1"><title>Actions</title><p id="p0365"><list list-type="simple" id="ulist0030"><list-item id="u0085"><label>•</label><p id="p0370">Consider administration of stress-dose corticosteroids for mothers treated with steroids antepartum to prevent Addisonian crisis</p></list-item><list-item id="u0090"><label>•</label><p id="p0375">To reduce perinatal infection, the newborn should have early clamping of the umbilical cord and early cleansing to remove maternal blood and amniotic fluid</p></list-item><list-item id="u0095"><label>•</label><p id="p0380">All neonates born to mothers with SARS should be admitted to the designated negative pressure isolation room in the neonatal nursery</p></list-item></list></p></sec><sec id="sec5.6.2.2"><title>Communications</title><p id="p0385"><list list-type="simple" id="ulist0035"><list-item id="u0100"><label>•</label><p id="p0390">Present anaesthetic options to labouring mother; neither epidural nor spinal anaesthesia is contraindicated and in some cases may be preferable to general anaesthesia. In cases where mothers are already ventilated, general anaesthesia for delivery may be most appropriate</p></list-item></list></p></sec></sec><sec id="sec5.6.3"><title>Postnatal management</title><sec id="sec5.6.3.1"><title>Actions</title><p id="p0395"><list list-type="simple" id="ulist0040"><list-item id="u0105"><label>•</label><p id="p0400">The mother should not breastfeed until she has recovered from SARS</p></list-item><list-item id="u0110"><label>•</label><p id="p0405">To minimize neonatal transmission risk, the mother should be isolated from the neonate until she has recovered from SARS and is considered no longer infectious</p></list-item></list></p></sec><sec id="sec5.6.3.2"><title>Communications</title><p id="p0410"><list list-type="simple" id="ulist0045"><list-item id="u0115"><label>•</label><p id="p0415">Support should be given to the mother and her family to cope with separation from her neonate, potential prolonged maternal hospitalization, parenting issues, neonatal nutrition, and breast engorgement</p></list-item><list-item id="u0120"><label>•</label><p id="p0420">As separation of mother and neonate may last for less than 10 days, breast pumping is recommended so that breastfeeding may begin once isolation has been discontinued</p></list-item></list></p></sec></sec><sec id="sec5.6.4"><title>Neonatal resuscitation</title><sec id="sec5.6.4.1"><title>Actions</title><p id="p0425"><list list-type="simple" id="ulist0050"><list-item id="u0125"><label>•</label><p id="p0430">Neonates should be admitted to the isolation ward of the neonatal nursery for observation and are considered as potentially infectious until 10 days post-delivery</p></list-item><list-item id="u0130"><label>•</label><p id="p0435">Preliminary testing for SARS should be performed, including blood tests and X-rays</p></list-item><list-item id="u0135"><label>•</label><p id="p0440">The infant should not be breastfed/given breast milk; formula should be used until the mother is considered no longer infectious.</p></list-item></list></p></sec><sec id="sec5.6.4.2"><title>Communications</title><p id="p0445"><list list-type="simple" id="ulist0055"><list-item id="u0140"><label>•</label><p id="p0450">Parents and family are counselled to look for symptoms and signs of SARS in the mother and newborn, especially in the first 10 days following delivery</p></list-item></list></p></sec></sec></sec><sec id="sec5.7"><title>Suggested Management Guidelines for Pregnant Women With Suspected SARS</title><sec id="sec5.7.1"><title>Labour triage and antenatal hospital admission</title><sec id="sec5.7.1.1"><title>Actions</title><p id="p0455"><list list-type="simple" id="ulist0060"><list-item id="u0145"><label>•</label><p id="p0460">Initial assessment and management is the same as for pregnant women with probable SARS</p></list-item><list-item id="u0150"><label>•</label><p id="p0465">If patient does not have symptoms, then placement in a negative pressure isolation room is not needed</p></list-item><list-item id="u0155"><label>•</label><p id="p0470">The patient should be monitored for symptoms and signs of SARS for a 10-day period</p></list-item></list></p></sec></sec><sec id="sec5.7.2"><title>Delivery</title><sec id="sec5.7.2.1"><title>Actions</title><p id="p0475"><list list-type="simple" id="ulist0065"><list-item id="u0160"><label>•</label><p id="p0480">Asymptomatic mothers with a history of SARS exposure should be monitored closely for symptoms and signs (e.g., temperature measured 2–4 times daily), and they should be transferred to the negative pressure isolation room if symptoms or signs develop</p></list-item><list-item id="u0165"><label>•</label><p id="p0485">If symptoms or signs develop, delivery, whether vaginal or Caesarean, should occur in the designated SARS delivery room, which is equipped with negative pressure ventilation</p></list-item></list></p></sec></sec><sec id="sec5.7.3"><title>Postnatal management</title><sec id="sec5.7.3.1"><title>Actions</title><p id="p0490"><list list-type="simple" id="ulist0070"><list-item id="u0170"><label>•</label><p id="p0495">Asymptomatic mothers with a history of SARS exposure should be monitored closely for symptoms and signs (e.g., temperature measured 2–4 times daily) and transferred to the negative pressure isolation room if symptoms or signs develop</p></list-item><list-item id="u0175"><label>•</label><p id="p0500">The mother should not breastfeed until she has recovered from SARS or is deemed not to have SARS</p></list-item><list-item id="u0180"><label>•</label><p id="p0505">To minimize neonatal transmission risk, the mother should be isolated from the neonate until she is no longer potentially infectious</p></list-item></list></p></sec><sec id="sec5.7.3.2"><title>Communications</title><p id="p0510"><list list-type="simple" id="ulist0075"><list-item id="u0185"><label>•</label><p id="p0515">Support should be given to the mother and her family to cope with separation from her neonate, potential prolonged maternal hospitalization, parenting issues, neonatal nutrition, and breast engorgement</p></list-item><list-item id="u0190"><label>•</label><p id="p0520">As separation of mother and neonate may last for less than 10 days, breast pumping is recommended so that breastfeeding may begin once isolation has been discontinued</p></list-item></list></p></sec></sec><sec id="sec5.7.4"><title>Neonatal resuscitation</title><sec id="sec5.7.4.1"><title>Actions</title><p id="p0525"><list list-type="simple" id="ulist0080"><list-item id="u0195"><label>•</label><p id="p0530">Neonates born to mothers with potential SARS close contact are considered to be potentially infectious until 10 days postpartum</p></list-item><list-item id="u0200"><label>•</label><p id="p0535">Preliminary testing for SARS is performed on the neonate only if mother or neonate has symptoms or signs of SARS</p></list-item><list-item id="u0205"><label>•</label><p id="p0540">If the mother remains asymptomatic, consider discharge of the neonate with the mother</p></list-item></list></p></sec><sec id="sec5.7.4.2"><title>Communications</title><p id="p0545"><list list-type="simple" id="ulist0085"><list-item id="u0210"><label>•</label><p id="p0550">Parents and family are counselled to look for symptoms and signs of SARS in the mother and newborn, especially in the first 10 days following delivery, and to report to any findings to the health care team</p></list-item></list></p></sec></sec></sec></sec><sec id="sec6"><title>Summary</title><p id="p0555">SARS, a life-threatening respiratory illness caused by a novel coronavirus, was responsible for a worldwide outbreak in 2003. SARS has been responsible for serious illness in over 250 Canadians and for 43 deaths since 2003. Given the highly infectious nature of SARS, diagnosis, treatment and containment procedures must be aggressively pursued in all medical communities to prevent epidemic spread. Special consideration must be given to the labour and delivery ward where mothers, their babies, and families are potentially placed at risk by exposure to an infected individual. In addition, special procedures must be instituted to protect labour and delivery personnel, who may have prolonged contact with labouring women and substantial exposure to body fluids at the time delivery and neonatal resuscitation. This document outlines a suggested management strategy for pregnant patients with SARS on the labour and delivery ward. This protocol may be of use for other emerging life-threatening infectious diseases.<boxed-text id="dtbox2"><caption><title>Recommendations</title></caption><p id="p0560">The quality of evidence reported in this document has been assessed using the Evaluation of Evidence criteria in the Report of the Canadian Task Force on Preventive Health Care (<xref rid="tbl1" ref-type="table">Table</xref>).<xref rid="bib40" ref-type="bibr"><sup>40</sup></xref><list list-type="simple" id="olist0015"><list-item id="o0060"><label>1.</label><p id="p0565">All hospitals should have infection control systems in place to ensure that alerts regarding changes in exposure risk factors for SARS or other potentially serious communicable diseases are conveyed promptly to clinical units, including the labour and delivery unit (III-C).</p></list-item><list-item id="o0065"><label>2.</label><p id="p0570">At times of SARS outbreaks, all pregnant patients being assessed or admitted to the hospital should be screened for symptoms of and risk factors for SARS (III-C).</p></list-item><list-item id="o0070"><label>3.</label><p id="p0575">Upon arrival in the labour triage unit, pregnant patients with suspected and probable SARS should be placed in a negative pressure isolation room with at least 6 air exchanges per hour. All labour and delivery units caring for suspected and probable SARS should have available at least one room in which patients can safely labour and deliver while in need of airborne isolation (III-C).</p></list-item><list-item id="o0075"><label>4.</label><p id="p0580">If possible, labour and delivery (including operative delivery or Caesarean section) should be managed in a designated negative pressure isolation room, by designated personnel with specialized infection control preparation and protective gear (III-C).</p></list-item><list-item id="o0080"><label>5.</label><p id="p0585">Either regional or general anaesthesia may be appropriate for delivery of patients with SARS (III-C).</p></list-item><list-item id="o0085"><label>6.</label><p id="p0590">Neonates of mothers with SARS should be isolated in a designated unit until the infant has been well for 10 days, or until the mother’s period of isolation is complete. The mother should not breastfeed during this period (III-C).</p></list-item><list-item id="o0090"><label>7.</label><p id="p0595">A multidisciplinary team, consisting of obstetricians, nurses, pediatricians, infection control specialists, respiratory therapists, and anaesthesiologists, should be identified in each unit and be responsible for the unit organization and implementation of SARS management protocols (III-C).</p></list-item><list-item id="o0095"><label>8.</label><p id="p0600">Staff caring for pregnant SARS patients should not care for other pregnant patients. Staff caring for pregnant SARS patients should be actively monitored for fever and other symptoms of SARS. Such individuals should not work in the presence of any SARS symptoms within 10 days of exposure to a SARS patient (III-C).</p></list-item><list-item id="o0100"><label>9.</label><p id="p0605">All health care personnel, trainees, and support staff should be trained in infection control management and containment to prevent spread of the SARS virus (III-A).</p></list-item><list-item id="o0105"><label>10.</label><p id="p0610">Regional health authorities in conjunction with hospital staff should consider designating specific facilities or health care units, including primary, secondary, or tertiary health care centres, to care for patients with SARS or similar illnesses (III-A).</p></list-item></list></p></boxed-text></p></sec></body><back><ref-list id="cebib0010"><title>References</title><ref id="bib1"><label>1</label><element-citation publication-type="other" id="sref1"><person-group person-group-type="author"><collab>World Health Organization</collab></person-group><article-title>WHO 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