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X• Vertical transmission: Yes/No?

• Setting up of a birthing room
• Precautions in Delivery Room
• Neonatal Resuscitation for Neonates born from COVID-
19 mother
• Newborn Care
• Breast Milk Feeding and Safe Handling of Containers
• Newborn Viral Testing
• Post Discharge Care
 Vertical transmission of COVID-19 to
Newborn: PRO and CONS

• Limited data, uncertain, inconclusive

• Congenital and perinatal transmission to newborns from infected women à
infrequent
• Primary infectious fluids for human-to-human transmission: Respiratory
secretions (droplet) and saliva

Karen M. Puopolo, M.D. Ph.D., Mark L. Hudak, M.D., David W. Kimberlin, M.D., James Cummings, M.D. Management of Infants Born to Mothers with COVID-19 Date of Document: April 2, 2020. American Academy of Pediatrics
Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases
 Emerging Microbes & Infections
2020, VOL. 9
Detectable 2019-nCoV viral RNA in blood is a
strong indicator for the further clinical severity

• Unexpectedly, the 2109-nCoV RNA was detected in the blood

(6 of 57 patients) and the anal swabs (11 of 28 patients).

• Detectable viral RNA in the blood and anal swab progressed

to severe symptom stage à strong correlation of serum viral
RNA with the disease severity

Chen W, Lan Y, Yuan X, Deng X, Li Y, Cai X, Li L, He R, Tan Y, Deng X, Gao M. Detectable 2019-nCoV viral RNA in blood is a strong indicator for the further clinical severity. Emerging microbes & infections. 2020 Jan 1;9(1):469-73.
 Vertical Transmission of Coronavirus Disease
19 (COVID-19) from Infected Pregnant
Mothers to Neonates: A Review
• A total of 31 infected pregnant mothers with COVID-19 were
reported.
• No COVID-19 infection was detected in their neonates or
placentas.
• No evidence for intrauterine transmission of COVID-19 from
infected pregnant women to their fetuses
 Antibodies in Infants Born to Mothers
With COVID-19 Pneumonia

• Neonatal throat swabs and blood samples all had negative RT-PCR test results.
• All 6 infants had antibodies detected in their serum.
Zeng H, Xu C, Fan J, Tang Y, Deng Q, Zhang W, Long X. Antibodies in infants born to mothers with COVID-19 pneumonia. Jama. 2020 Mar 26.
 Antibodies in Infants Born to Mothers
With COVID-19 Pneumonia

• IgG is passively transferred across the placenta from mother to fetus

• At the end of the 2nd trimester, reaches high levels at the time of birth.
• However, IgM is not usually transferred from mother to fetus
• because of its larger macromolecular structure.
• The placentas of 2 women who were convalescing from SARS-CoV infection
in the 3rd trimester of pregnancy had abnormal weights and pathology.
• Alternatively IgM could have been produced by the infant if the virus
crossed the placenta à still inconclusive??

Zeng H, Xu C, Fan J, Tang Y, Deng Q, Zhang W, Long X. Antibodies in infants born to mothers with COVID-19 pneumonia. Jama. 2020 Mar 26.
 Clinical characteristics and intrauterine vertical transmission
potential of COVID-19 infection in nine pregnant women:
a retrospective review of medical records

• ALL mother had confirmatory test (SARS-CoV-2 quantitative RT-

PCR): POSITIVE
• The presence of SARS-CoV-2 was tested in amniotic fluid, cord
blood, neonatal throat swab, and breastmilk samples: ALL
NEGATIVE
• Questions:
• vaginal delivery increases the risk of mother-to-child intrapartum
transmission?
• uterine contraction increase the possibility of the virus ascending?
• COVID-19 could damage the placenta, which represents an important link
in vertical transmission?
• Needs further investigation

Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, Li J, Zhao D, Xu D, Gong Q, Liao J. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical
records. The Lancet. 2020 Mar 7;395(10226):809-15.
 Birth Mode

• No evidence that vaginal delivery increases the risk

of transmission (ACOG, WHO)
• In Indonesia, Caesarean delivery is preferred using
negative pressure (POGI)
• In limited facilities à modified operating room
• Turn off the AC
• In case of spontaneous birth à prefer use delivery
* Modified delivery chamber chamber & 3rd level precautions
*The picture use Level 2 Precautions

Rekomendasi Perkumpulan Obstetri Ginekologi Indonesia (POGI) mengenai kesehatan ibu pada Pandemi Covid 19
 Recommended Personal Protective
Equipment (PPE) - CDC
• The minimum PPE recommended:
• A single pair of disposable examination gloves
• Disposable isolation gown or single-
use/disposable coveralls
• Any NIOSH-approved particulate respirator
(i.e., N-95 or higher-
level respirator); facemasks are an acceptable
alternative until the supply chain is restored
• Eye protection (i.e., goggles or disposable
face shield that fully covers the front and
sides of the face).
https://www.cdc.gov/coronavirus/2019-ncov/downloads/guidance-law-enforcement.pdf
 Setting up of a birthing room
(for spontaneous birth as well as Caesarean Section)

• for a patient with suspected or

confirmed COVID-19 undergoing labor
and delivery
• A negative pressure room is preferred
• Limited number of providers in the room
• Additional personnel may be outside the
room and be available (if extensive
neonatal resuscitation is needed)
• Professional providers
• Prepare video-laryngoscope if possible in
case need of intubation
 Neonatal Resuscitation
- for newborn born from mother with
suspected/confirm COVID-19

OR

• No delayed cord clamping (preferred if mother is symptomatic)

• No skin–to-skin contact
Chandrasekharan P, Vento M, Trevisanuto D, Partridge E, Underwood MA, Wiedeman J, Katheria A, Lakshminrusimha S. Neonatal Resuscitation and Postresuscitation Care of Infants Born to Mothers with Suspected or Confirmed
SARS-CoV-2 Infection. American Journal of Perinatology. 2020 Apr 8.
 Neonatal Resuscitation

Airway Management
• Clearing the airway by suctioning could generate aerosols
• Should use adequate PPE!
• A neonate who requires positive pressure ventilation (PPV), the
resuscitation is performed as per AAP and NRP recommended
parameters and target saturations with supplemental oxygen.
• Personnel involved in the placement of an advanced airway, such
as an endotracheal tube
• take precautions (N95 masks, face shields/goggles, and
double glove)
• The most experienced provider should perform intubation and
other procedures to limit aerosol generation.

Chandrasekharan P, Vento M, Trevisanuto D, Partridge E, Underwood MA, Wiedeman J, Katheria A, Lakshminrusimha S. Neonatal Resuscitation and Postresuscitation Care of Infants Born to Mothers with Suspected or Confirmed
SARS-CoV-2 Infection. American Journal of Perinatology. 2020 Apr 8.
Neonatal Resuscitation

Giving respiratory support

• Ensure a good CPAP seal, use 2 hand method

• Turn off Neopuff Flow when removing mask
from the infant or disconnecting neopuff
from the ETT

COVID-19 – Guideline Neonatal care of infants born to women with suspected or confirmed COVID-19. Canberra Health Services
 Neonatal Transport
Transport to NICU (if required)
• If ongoing invasive ventilation is required à the flow will be
stopped, then disconnect infant from respiratory support
and with the HME filter to remain on the ETT during this
activity.
• If ongoing NIV (CPAP) is required, the flow will be stopped
with CPAP interrupted, the baby will be “carried” from
resuscitaire to isolette and shuttle or mansel in the “green
or amber zone”
• If using bubble CPAP for transport on the shuttle, a viral
filter (preferred) (or HME filter) should be used on the
expiratory limb of the CPAP
• The team transporting the newborn to keep PPE on,
changing gloves and any other visibly contaminated PPE

COVID-19 – Guideline Neonatal care of infants born to women with suspected or confirmed COVID-19. Canberra Health Services
 Newborn Care Baby was given face shield to
avoid droplet infections (for
• Neonates born to women with COVID-19 or with testing for COVID-19 newborn with pending
pending at the time of delivery à considered as persons under laboratory result)
investigation (PUIs) for infection
• Isolate the baby from infant born from non COVID-19 mother
• Temporary separation of mother and newborn
• minimize the risk of postnatal infant infection from maternal respiratory
secretions.

• Newborns should be bathed as soon as reasonably possible after birth

à to remove virus potentially present on skin surfaces.

• Infants born requiring neonatal intensive care optimally should be

admitted to a single patient room with the potential for negative room
pressure
• If not available: maintained at least 6 feet apart and/or placed in air
temperature-controlled isolation room

• Faecal material waste à possibility of transmission until 10-14 days

• Need special management
Karen M. Puopolo, M.D. Ph.D., Mark L. Hudak, M.D., David W. Kimberlin, M.D., James Cummings, M.D. Management of Infants Born to Mothers with COVID-19 Date of Document: April 2, 2020. American Academy of Pediatrics
Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases
 Non-invasive ventilation (NIV) in the NICU for
newborns at risk of confirmed COVID-19
• NIV and high flow therapies à significant aerosolization,
considered high risk.
• Infants requiring NIV respiratory due to suspected or confirmed
COVID-19 disease
• nursed in an incubator in a negative pressure room (if available)
• Heat and moisture exchanger (HME) filter
• should be used between mask/ETT and neopuff T piece/ventilator circuit
• in order to stop aerosol generation from the expiratory valve or ET tube
• Actively heated and humidified ‘wet circuits’ à increase risks of
contamination of the room if there is an unexpected circuit
disconnection
• Avoid unnecessary circuit disconnections
• Turn flow off prior to disconnecting CPAP/Neopuff/Vent
• Wear airborn PPE during all cares
COVID-19 – Guideline Neonatal care of infants born to women with suspected or confirmed COVID-19. Canberra Health Services
 Breast Milk Feeding
• No study has demonstrated the
presence of SARS-CoV-2 in breast LESS PREFFERED
• Safety of breastfeeding when
mother is on antiviral therapy
remains unknown.
• Mothers may express breast milk
• after appropriate breast and hand
hygiene
• be fed to the infant by designated
caregivers.
• Breast pumps and components
should be thoroughly cleaned in
between pumping sessions Women with COVID-19 can breastfeed if they wish to do so.
• cleaning the pump with disinfectant • Practice respiratory hygiene during feeding
wipes • wearing a mask
• washing pump attachments with • Wash hands before and after touching the baby
hot soapy water. • Routinely clean and disinfect surfaces they have touched.
Karen M. Puopolo, M.D. Ph.D., Mark L. Hudak, M.D., David W. Kimberlin, M.D., James Cummings, M.D. Management of Infants Born to Mothers with COVID-19 Date of Document: April 2, 2020. American Academy of Pediatrics
Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases
 Safe Handling of Containers of Expressed
Human Milk During the SARS-CoV-2 (COVID-
19) Pandemic
COVID-19 virus contaminates surfaces from respiratory droplet spread
• Mothers should wear respiratory masks and practice effective hand washing.
• Containers must be disinfected after milk expression
• Using viricidal agents or appropriate bleach solutions
• Before storage in milk banks, hospital wards, day care centers, etc

Recommendations for Handling Containers of Human Milk After Milk is Expressed.

• Receive containers from mothers or boxes of donor milk with gloved hands
• Wipe down the outside surface of the individual milk containers with disinfectant
•{ suggest viricidalagents already in place at hospitals, donor milk banks, etc.
•{ alternatively use “high level disinfection” of 0.5% solution, a dilution of 1:10 diluted bleach (sodium hypochlorite [NaOCl])

• Set wiped containers in a rack or on a tray to dry (wet to dry ensures time for viricidal effect) before storing in refrigerators or freezers
• For hospital wards/neonatal intensive care units, separate bins for each infant in the same refrigerator are fine once the containers have been wiped down
• Resume usual protocol
Marinelli KA, Lawrence RM. Safe Handling of Containers of Expressed Human Milk in all Settings During the SARS-CoV-2 (COVID-19) Pandemic. Journal of Human Lactation. 2020 Apr 3:0890334420919083.
 Newborn Viral Testing
Ideally, neonates should be tested for SARS- CoV-2 infection
using available molecular assays
• Especially require prolonged neonatal intensive care
• If not available: clinical monitoring only.
1. Real Time Polymerase Chain Reaction (RT-PCR) à considered the gold standard
2. Molecular assay testing: at 24 hours of age
3. Repeat testing at 48 hours of age
• For well newborns who will be discharged à may consider not obtaining this test
4. At each test, consider using swabs of throat and nasopharynx (+rectal swab)
5. For infants who are positive on their initial PCR testing
• follow-up testing of combined specimens from the throat and nasopharynx
• at 48-72 hour intervals until two consecutive negative tests.

Karen M. Puopolo, M.D. Ph.D., Mark L. Hudak, M.D., David W. Kimberlin, M.D., James Cummings, M.D. Management of Infants Born to Mothers with COVID-19 Date of Document: April 2, 2020. American Academy of Pediatrics
Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases
Alur Pemeriksaan rapid test
SARS-CoV2 (COVID-19)
Usulan PDS PatKlin
 Post Discharge Care
• Infants determined to be infected by • Infants with negative SARS-CoV-2
molecular testing (or whose status cannot molecular testing should be discharged to
be determined due to lack of testing), but the care of a designated healthy (non-
with no symptoms of COVID-19 infected) caregiver.

• If the mother is in the same household

• may be discharged with appropriate à maintain a distance of at least 6 feet
precautions • Mother should use a mask and hand
• plans for frequent outpatient follow-up hygiene for home newborn care until
contacts through 14 days after birth. EITHER
• either by phone, telemedicine, or in-office • (a) she has been afebrile for 72 hours
without use of antipyretics, and
• Use of standard procedural masks, gloves • (b) at least 7 days have passed since
and hand hygiene to all caretakers. symptoms first appeared;
• Uninfected individuals >60 years of age • OR she has negative results of a molecular
and those with comorbid conditions assay for detection of SARS-CoV-2 from at
least two consecutive nasopharyngeal
should not provide care if possible. swab specimens collected ≥24 hours apart.

Karen M. Puopolo, M.D. Ph.D., Mark L. Hudak, M.D., David W. Kimberlin, M.D., James Cummings, M.D. Management of Infants Born to Mothers with COVID-19 Date of Document: April 2, 2020. American Academy of Pediatrics
Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases
 Maternal visitation for infants requiring
ongoing hospital care

Mothers with COVID-19 should not visit infants requiring NICU until:
• Resolution of fever without the use of antipyretics for at least 72 hours and
• Improvement (but not full resolution) in respiratory symptoms and
• Negative results of a molecular assay for detection of SARS-CoV-2 from at least two consecutive
nasopharyngeal swab specimens collected ≥24 hours apart
 Conclusion

1. Inconsistent evidence of vertical transmission from

mother to infant
2. No evidence of presence of virus in amniotic fluid, breast
milk and placenta
3. Likely sources of transmission to newborn:
• maternal respiration secretion after birth
• environmental
RSCM KIARA
Any Questions?
 Neonatal Early-Onset Infection With SARS-CoV-2
in 33 Neonates Born to Mothers With COVID-19
in Wuhan, China
Because strict infection control and prevention procedures were implemented during the
delivery, it is likely that the sources of SARS-CoV-2 in the neonates’ upper respiratory tracts
or anuses were maternal in origin

Patient 1 Patient 2 Patient 3

• 40 weeks’ gestation • 40 weeks’ and 4 days’ gestation • 31 weeks’ and 2 days’ gestation
• Cesarean delivery because of • Cesarean delivery because of confirmed • Cesarean delivery because of fetal distress and
meconium-stained amniotic fluid maternal COVID-19 pneumonia. confirmed maternal COVID-19 pneumonia
and confirmed maternal COVID-19 • He presented with lethargy, vomiting, • Resuscitation was required
pneumonia and fever. • Apgar scores were 3/4/5 at 1/5/10 minutes
• Day 2 of life: lethargy and fever • Laboratory tests showed leukocytosis, • Neonatal respiratory distress syndrome and
• A chest Xray: pneumonia lymphocytopenia, and an elevated pneumonia confirmed by chest radiographic
• Laboratory tests (except creatine kinase–MB fraction image on admission resolved on day 14th
procalcitonin) were normal • A chest Xray: pneumonia • Tx: noninvasive ventilation, caffeine, and
• Nasopharyngeal and anal swabs • Nasopharyngeal and anal swabs were antibiotics.
were positive for SARS-CoV-2 on positive for SARS-CoV-2 on days 2 and 4 • Nasopharyngeal and anal swabs were positive
days 2 and 4 of life and negative on of life and negative on day 6. for SARS-CoV-2 on days 2 and 4 of life and
day 6. negative on day 7.
Zeng L, Xia S, Yuan W, Yan K, Xiao F, Shao J, Zhou W. Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China. JAMA pediatrics. 2020 Mar 26.
 Rapid test Antibody

Yang direkomendasikan • Xiamen InnoDx Biotech Co - Novel Coronavirus (2019-nCoV)Antibody

Test Kit (CLIA method)
• CTK Biotech - OnSite COVID-19 IgG/IgM Rapid Test
• Guangdong Hecin Biotech Co - Novel Coronavirus (2019-nCoV) IgM
• Hangzhou Biotest Biotech- COVID-19 IgG/IgM Rapid Test Cassette Antibody test Kit (colloidal gold method)
(Whole Blood/Serum/Plasma)
• Nanjing Vazyme Biotech Co - Novel Coronavirus (2019-nCoV) IgM/IgG
• Innovita Biological Technology - 2019-nCoV Ab Test (Colloidal Gold) Antibody Test Kit (colloidal gold method)
(IgM/IgG Whole Blood/Serum/Plasma Combo)
•
• SD Biosensor Inc - STANDARD Q COVID-19 IgM/IgG Duo Test 

Tambahan:
• VivaChek Biotech - VivaDiag COVID-19 IgM/IgG Rapid Test 

• Cellex qSARS-CoV-2 IgGIgM Cassette Rapid Test (Lateral flow method) -
Alternatif: Cellex, Inc

• Zhihai Livzon Diagnostics - Diagnostic Kit for IgM Antibody to Corona • COVID-19 IgG/IgM Rapid Test Cassette - Hangzhou Clongene Biotech
Virus(nCoV-2019) (Colloidal Gold) 
 Co., Ltd
• Autobio Diagnostics - Anti-SARS-CoV-2 Rapid Test

• Coronacide - COVID-19 IgM/IgG Rapid Test 

• Guangzhou Wondfo Biotech Co - Wondfo SARS-CoV-2 antibody test
(Lateral Flow Method)
• Bioscience (Chongqing) Biotech Co - Novel Coronaviru(s 2019-nCoV)
IgM Antibody Test Ki(t magnetic particle chemiluminescence method
 Neonatal admission bed spaces
• First high risk or confirmed COVID-19 will be admitted to NICU
isolation room
• Then admit to 2 bedded room (32 to 35) and close other bed or
cohort the whole room as COVID-19 risk if not on CPAP (in enclosed
crib)
• Next option if another single room required is to consider SCN
isolation room or treatment room in SCN.
• For readmission or infants with COVID-19 admit to NICU isolation
room or SCN isolation room (NOT open room)
• Aim is not to cohort infants requiring CPAP. If there is a mix of
infants requiring CPAP and infants not requiring respiratory support,
use second 2 bedded room in NICU.

COVID-19 – Guideline Neonatal care of infants born to women with suspected or confirmed COVID-19. Canberra Health Services
 Precautions in Delivery Room for Newborn
Baby born from mother with suspected/ confirm
Baby born from healthy mother COVID-19

Ideal setting where

hazmat is available

In limited facilities where

hazmat is not available, provider
may use level 2 precautions
(without Hazmat)
Karen M. Puopolo, M.D. Ph.D., Mark L. Hudak, M.D., David W. Kimberlin, M.D., James Cummings, M.D. Management of Infants Born to Mothers with COVID-19 Date of Document: April 2, 2020. American Academy of Pediatrics Committee on Fetus and Newborn,
Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases
 Well Appearance Baby
Baby’s condition is improving but
still need minimal respiratory Baby needs intensive
support care
Level 1
MODIFIKASI

face shield for well

appearance baby born
from mother with
suspected/confirm
COVID-19

Droplet and Contact Precautions: • When patients require active

• used for most encounters with infants
born to mothers with COVID-19 in
perinatal ward.
• Baby may infect health worker by
respiratory droplet (when crying) or by
faeces
Airborne, Contact and Droplet resuscitation, bag-mask
Precautions ventilation, intubation, tracheal
Use in perinatal ward when the baby suctioning, nasal cannula O2 at a
still need oxygen (low flow with flow greater than 2 lpm, CPAP
oxygen flow <2 liters per minute) • In limited facilities where hazmat
is not available, provider may use
level 2 precautions