Received: 4 March 2020 | Accepted: 22 March 2020

DOI: 10.1002/jmv.25787

REVIEW

Maternal health care management during the outbreak

of coronavirus disease 2019

Yu Chen MD1 | Zhe Li MD2 | Yuan‐Yuan Zhang MD1 | Wei‐Hua Zhao MD, PhD3 |
Zhi‐Ying Yu MD1

1
Department of Gynecology, Shenzhen Second
People's Hospital/the First Affiliated Hospital Abstract
of Shenzhen University Health Science Center,
Shenzhen, China Coronavirus disease 2019 (COVID‐19) is a novel type of highly contagious
2
The First Clinical Medical College of Southern pneumonia caused by the severe acute respiratory syndrome coronavirus 2
Medical University, Guangzhou, China
(SARS‐CoV‐2). Despite the strong efforts taken to control the epidemic, hundreds of
3
Department of Obstetrics, Shenzhen Second
People's Hospital/the First Affiliated Hospital thousands of people were infected worldwide by 11 March, and the situation was
of Shenzhen University Health Science Center, characterized as a pandemic by the World Health Organization. Pregnant women
Shenzhen, China
are more susceptible to viral infection due to immune and anatomic alteration,
Correspondence though hospital visits may increase the chance of infection, the lack of medical care
Zhi‐Ying Yu, MD, Department of Gynecology,
Shenzhen Second People's Hospital/the First during pregnancy may do more harm. Hence, a well‐managed system that allows
Affiliated Hospital of Shenzhen University pregnant women to access maternal health care with minimum exposure risk is
Health Science Center, 518035 Shenzhen,
China. desired during the outbreak. Here, we present the managing processes of three
Email: lizheyzy@163.com pregnant women who had fever during hospitalization in the gynecology or ob-
Wei‐Hua Zhao, MD, PhD, Department of
stetrics department, and then, we further summarize and demonstrate our maternal
Obstetrics, Shenzhen Second People's
Hospital/the First Affiliated Hospital of health care management strategies including antenatal care planning, patient triage
Shenzhen University Health Science Center,
based on the risk level, admission control, and measures counteracting emergencies
518035 Shenzhen, China.
Email: zwhzyz123@163.com and newly discovered high‐risk cases at in‐patient department. In the meantime, we
will explain the alterations we have done throughout different stages of the epi-
Funding information
Shenzhen Science and Technology Innovation demic and also review relative articles in both Chinese and English to compare our
Committee, Grant/Award Numbers: strategies with those of other areas. Although tens of COVID‐19 cases were con-
JCYJ20170817172241688,
JCYJ20180228163529609; Shenzhen firmed in our hospital, no nosocomial infection has occurred and none of the
Municipal Health Commission, pregnant women registered in our hospital was reported to be infected.
Grant/Award Number: SZSM201812041;
Shenzhen Second People's Hospital/ the First
Affiliated Hospital of Shenzhen University KEYWORDS
Health Science Center, Grant/Award Number: 2019 coronavirus disease, 2019 novel coronavirus, antenatal care, health care management,
4001023
maternal health, nosocomial infection, pregnant, severe acute respiratory syndrome coronavirus 2

1 | INTRODUCTION
With the arrival of New Year in December 2019, a novel type of
coronavirus emerged and soon became epidemic. To the best of our
knowledge, the earliest onset of symptom was reported in a patient
who was later diagnosed with “pneumonia of unknown etiology” on
1 December 2019,1 and then in late December 2019, several local
hospitals reported similar cases in Wuhan, Hubei Province, China.2
On 6 January, an “unknown pathogen” was examined and identified
as 2019 novel coronavirus (2019‐nCoV); it was later renamed as
severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) with
regard to the features of the virus and the disease was termed 2019

Yu Chen and Zhe Li contributed equally to this study.

J Med Virol. 2020;92:731–739. wileyonlinelibrary.com/journal/jmv © 2020 Wiley Periodicals, Inc. | 731

732 | CHEN
coronavirus disease (COVID‐19).3 In spite of the strong efforts taken
to control the virus, 80 955 cases were confirmed in China by
4
11 March. As the domestic epidemic situation finally calmed down,
with only 31 new cases being reported nationwide in the past
24 hours, more and more outbreaks are being reported abroad. By 1
1 March, a total of 37 371 cases were reported outside China, af-
4
fecting 113 countries/territories/areas. On 11 March, WHO char-
acterized COVID‐19 as a pandemic.5
Coronaviruses are spherical, enveloped, single‐stranded RNA viru-
ses. By the end of 2019, six coronavirus species were proven to cause
diseases among humans. Among these six, HCoV‐229E, ‐NL63, ‐OC43,
and ‐HKU1 are the four prevalent types that cause common cold. Two
strains, on the contrary, account for fatal illness: severe acute
respiratory syndrome coronavirus (SARS‐CoV) and Middle East
6,7
respiratory syndrome coronavirus (MERS‐CoV). COVID‐19 shares
very similar transmission routes and clinical manifestations with SARS
and MERS; however, its infectivity is stronger than that of SARS and
8
MERS. Some specialists also suggested that the severity of COVID‐19
might be no weaker than SARS according to clinical observation.
Pregnant women are more susceptible to the virus due to immune and
anatomic alteration,9 although no data regarding the incidence and
fatality due to COVID‐19 are reported, the adverse pregnancy outcome
of SARS and MERS should raise an alert.10,11
Shenzhen is an immigrant city with a population of over 13 million
in China.12 Around the Chinese New Year, a mass population flow that
involved millions of migrant workers might be partially responsible for
the virus outbreak. Until 11 March, 420 cases were confirmed, making
Shenzhen the second infected city outside Hubei provenience. In addi-
tion, according to Shenzhen Municipal Health Commission, there were
187 880 parturients in 2018.13 Thus, maternal health management
during the COVID‐19 outbreak became extremely important. In this
article, we will demonstrate the management process of three pregnant
women who presented fever after being admitted to gynecology or
obstetrics department. Then, we further illustrate our maternal health
care management strategies that were developed and modified by re-
ferring to the guidelines formulated by specialists from Wuhan and
other cities in adjustment to local situations in Shenzhen and our hos-
pital. Meanwhile, the literature review of Chinese and English publica-
tions referring to such topic is done to compare some of our managing
strategies with those of other areas.
2 | C AS E R E P O RT
2.1 | Case 1
A 25‐year‐old female with a history of normal menstruation visited
our hospital owing to lower abdominal pain at 47 days of amenor-
rhea. The patient appeared to be in a generally stable condition, so
she was asked to finish an epidemiological evaluation including
contact history, clinical signs, and body temperature (detailed criteria
listed in the next section) before she was allowed into the out‐patient
building. Then, based on her symptoms, she was referred to the
ET AL.
department of gynecology. The patient complained pain in the lower
abdominal area, and palpation indicated tenderness in bilateral ad-
nexa areas, especially on the right side. Urine human chorionic go-
nadotropin (HCG) was positive and ultrasound displayed a
22 × 16 mm mass on her right adnexa, and free liquid areas that
measured 24 mm and 13 mm deep were also seen in the front and
back sides of her uterus separately. Based on the clinical manifes-
tations, she was suspected of ectopic pregnancy, which needed
hospitalization. Before admission, blood routine, blood HCG, and
viral nucleic acid test (nasopharyngeal swab, polymerase chain re-
action [PCR]) were taken; chest computed tomography (CT) was also
obtained after fully informing her about the risk of COVID‐19, the
possibility of infection with negative viral nucleic acid result,14 the
possibility of intrauterine pregnancy, and the potential risk of low‐
dose radiation exposure during pregnancy. Her blood routine test
showed that hemoglobin was 124 g/L, leukocyte count was
9.95 × 109, and lymphocyte count was 1.59 × 109, making her lym-
phocyte ratio 16%, which was below the normal range. Chest CT did
not indicate any abnormality. Considering the potential risk of tubal
rupture, she was admitted before other results came out but quar-
antined in a single‐bed ward.
After admission, she developed a mild fever measuring 37.5°C,
taken together that her lymphocyte ratio was below normal range, we
were alarmed. In addition, she complained that her abdominal pain was
intensified. Hence, we immediately informed all the staff in our de-
partment about the issue and the protection required when having
contact with her. Then, we informed the patient's family about her
current situation and gave them epidemiological evaluation and self‐
quarantine advice. Meanwhile, we retested blood routine and consulted
COVID‐19 and respiratory specialists. Blood routine showed that her
hemoglobin dropped from 124 to 113 g/L, but her leukocyte and
lymphocyte were the same as before, and her blood HCG was
9416.7 mIU/mL. Although her viral nucleic acid test result was not out
yet, we decided to perform surgery considering her condition. Both
COVID‐19 and respiratory specialists re‐evaluated her contact history,
clinical manifestations, test results, and CT images and concluded that
the evidence did not support SARS‐CoV‐2 infection. After informing the
operating room about the patient's COVID‐19‐related evaluation, her
operation was arranged. During the surgery, medical protective re-
spirator, goggles, disposable waterproof surgical gown were required
for all staffs. After surgery, although her temperature dropped to 37°C,
the patient was quarantined in her single‐bed ward again, and her body
temperature was monitored on an hourly basis until the viral nucleic
acid result come out negative. The next morning, we retested blood
routine, her leukocyte count dropped to 5.9 × 109/L, and her lympho-
cyte ratio raised to 22%, and it appeared that her fever was more likely
induced by her ectopic pregnancy.
2.2 | Case 2
A 28‐year‐old female, gravida 3 para 0, was admitted to the ob-
stetrics department for planned induced labor due to gestational
CHEN ET AL.
diabetes mellitus (GDM) at 40 + 6 gestational week. During the
pregnancy, no complication was detected other than GDM, and her
blood glucose was well controlled. Before admission, she denied
going to Hubei provenience or having direct contact with any con-
firmed COVID‐19 patient or people from Hubei provenience. She
also denied having COVID‐19‐related symptoms such as fever,
coughing, fatigue, sneezing, sore throat, or diarrhea recently. After
admission, in a routine temperature check (three times a day), her
body temperature was found to be 37.4°C, which was above the
normal range (below 37.3°C). After further digging the contact his-
tory, she found that a week ago one diagnosed patient was reported
visiting the apartment complex she lived in, but no one in that
apartment complex was infected by that time.
Although she did not meet the criteria (listed in the next section)
to be qualified as a suspected patient, she had two risk factors, which
are potential exposure to a diagnosed patient and fever. For pru-
dential reasons, we quarantined her in a single‐bed ward, took blood
routine and viral nucleic acid test, and started monitoring her body
temperature on an hourly basis within the first 3 hours and then once
every 4 hours. In the following 2 hours, her body temperature re-
mained above 37.3°C, so after fully informing her about relative risks,
she agreed for CT scans and the images showed a 3 × 2 mm mass in
the upper left lung lobe. We immediately consulted COVID‐19 spe-
cialist and doctor from respiratory department. After a careful study
of the images, both doctors suggested that the mass did not have a
typical COVID‐19 pneumonia appearance, which was later confirmed
by the negative viral nucleic acid test result. The patient's body
temperature dropped back to normal without any medical inter-
vention the next afternoon, though we kept watch on her body
temperature, the alarm was off and we performed induced labor, a
healthy newborn was delivered the next evening.
2.3 | Case 3
A 27‐year‐old female, gravida 1 para 0, had a regular 30‐day menstrual
cycle before her last menstrual period on 15 December 2019. At 5 weeks
of amenorrhea, she visited a hospital in Zhanjiang City, Guangdong
Province, intrauterine pregnancy with fetal heartbeat was discovered
using ultrasound at the time. At 11 weeks and 4 days of gestation, the
patient suffered spotting, ultrasound examination at a hospital in
Guangzhou showed intrauterine pregnancy without fetal heartbeat, and
then, at 12 + 5 gestational week, she came to our hospital. At first triage,
she was classified as low‐risk patient according to epidemiological eva-
luation, but as we were investigating her medical history, we learned that
she had traveled to two different cities, she took a train on the last trip,
and she also took subway twice in the past week. As her only discomfort
was mild vaginal bleeding, we prescribed CT scans and viral nucleic acid
tests before other checkups. In the afternoon, both reports were found to
be normal. Hence, after further serum and ultrasound check, we admitted
her to the in‐patient gynecology department.
After a regular misoprostol treatment, the patient started having a
mild fever (body temperature at 37.5°C). She also complained uterine
| 733
contraction, but her abdomen was soft, with no tenderness and rebound
tenderness being spotted during palpation. Though her fever was more
likely induced by other causes such as adverse reaction of misoprostol or
even infection, precautions were still taken. The patient was quarantined
in a single‐bed ward, and her body temperature was monitored once per
hour. Then, we further looked into her travel history. Now that all train,
plane or ship tickets are registered with identification number in China,
once someone is diagnosed, the passengers on the same transport will be
informed, hence people can also check whether they shared public
transportation with a COVID‐19 diagnosed patient. In addition, every
public transportation has its own QR code in Shenzhen, passengers are
advised to scan them to form an e‐trace for themselves. After thorough
investigation of her travel history, she didn't find any reported diagnosed
COVID‐19 case that shared transportation with her. We also took blood
routine, C‐reactive protein (CRP), procalcitonin (PCT), and viral nucleic
acid test. The results showed that leukocyte count, lymphocyte count,
CRP, and PCT were all within the normal range. Then, we invited COVID‐
19 and respiratory specialists. According to both doctors, there was no
sign of infection on the report of chest CT which she took 2 days ago, and
taken together that she did not have any respiratory symptoms, a second
CT scan was not needed. Two hours later, her body temperature dropped
back to 36.8°C, viral nucleic acid later also reported negative. Before viral
nucleic acid result came back, second‐level protection was requested for
all the staff who needed physical contact with her.
3 | MATERNAL MANAGEME NT
STR AT EGI ES
3.1 | Maternal health care advises during the
outbreak
To avoid further spread of the epidemic, people are advised to stay at
home, which brings up a dilemma for many pregnant women about
whether to go the hospital. First and foremost, intrauterine preg-
nancy confirmation and antenatal care are essential. Statistics show
that more than 2% pregnancy is ectopic,15 and birth defects or ge-
netic disorders occurs in approximately 3% to 5% pregnancies.16
Congenital malformations caused by genetic or chromosomal defects
not only threaten lives of the patients but also exert pain on their
families.17 Proper maternal health care not only significantly reduces
the occurrence and mortality of pregnancy complications18 but also
prevents congenital malformations.19 Meanwhile, the risk of ex-
posure can be reduced by self‐protection, patient triage according to
risk level, and early quarantine of suspected and diagnosed patients.
Therefore, canceling hospital visits may reduce the probability of
viral infection; the aftereffect could leave bigger impact.
During COVID‐19 outbreak, the following checkups are re-
commended. In the first trimester, ultrasonographic examination to
confirm intrauterine pregnancy after 6 weeks of amenorrhea is advised
by us. In Wuhan, similar recommendations are offered by Wuhan Mu-
nicipal Heath Commission, however, patients are advised to consult and
make appointment online prior to hospital visits. It is also recommended
734 | CHEN ET AL.

to first consult online when suffering discomfort such as lower abdominal
pain or vaginal bleeding. A list of non‐antiepidemic hospitals is publicized
so that pregnant women can choose safer access to regular antenatal
care. In addition, various platforms were set to offer medical consultation,
for pregnant women without complications and relative risk factors, some
surveillance may be done at home with the guide from medical profes-
20
sionals. Ultrasonographic examination of the nuchal translucency along
with serum tests including markers for chromosomal disorders, carrier
screening, and TORCH screen is advised to be done in one visit between
11 and 13 weeks 6 days’ gestation. For the second trimester, serum triple
screen and second‐trimester transabdominal ultrasonography are re-
commended to be done in one visit between 20 and 20 + 6 gestational
weeks. Oral glucose tolerance testing should be done between 24 and
28 weeks but can be replaced by low sugar diet and self‐blood glucose
monitor if a patient is undergoing home quarantine. During the third
trimester, two visits between 30 and 32 weeks and 36 and 37 weeks for
ultrasonographic examination and Group B streptococci test are re-
commended. These are in agreement with the recommendations given by
specialists from Sichuan and Liaoning provenience.21,22 In Wuhan, two
visits between 29 and 32 weeks and 37 and 41 weeks are also
recommended. For twins, ultrasonographic examination can also be
prolonged from once every 2 weeks to once every 4 weeks.20 Fetal heart
rate monitoring is advised but can be done at home if rental remote
monitoring device is equipped. Certain surveillance such as measurement
of uterine height, abdominal circumference, weight, fetal movement, and
blood pressure can be done at home. In addition, online courses and
medical consultations that offer medical advice such as antenatal checkup
plan, pregnancy management, self‐monitor, and self‐protection are
available through live broadcasting, online chatting, and social media
platforms for pregnant women.
3.2 | Patient triage based on risk level
To prevent nosocomial infection and superspreading event, we built up
strict triage and admission systems. All patients visiting our hospital
follow a standard triage procedure (Figure 1). At the first visit, all
nonemergency patients are asked to line‐up in the outdoor area with
at least 1 m distance between themselves for an epidemiological
evaluation,23 unless they claim to have contact history and demand a
direct visit to fever clinic. The criteria of the epidemiological evaluation
are recommended by National Health Commission, and it includes24:
(1) Travel or residential histories in Hubei provenience or other
areas with a local outbreak or communities that had reported
case within the past 14 days;

F I G U R E 1 Standardized procedure for out‐patient triage. *Potentially fatal emergencies include but not restricted to severe vaginal bleeding
without confirmed pregnancy, parturition, premature rupture of membranes, fetal distress, vaginal bleeding during pregnancy, and abnormal
vital signs (except fever)
CHEN ET AL.
(2) Exposure to those who had travel or residential histories in
Hubei or other areas with local outbreak or communities that
had reported case within the past 14 days and later presented
fever or respiratory symptoms;
(3) Exposure to suspected or diagnosed cases within the past
14 days;
(4) Exposed to a clustered onset;
(5) Respiratory symptoms and body temperature.
In a protocol issued by the First Affiliated Hospital of Nanchang
University, as well as the regulation in our hospital at the early
stages of the epidemic, those who have any of the above risk factors
would be referred to fever clinic.25 However, we soon realized that
this might put the majority of patients who were not infected at
higher a risk of exposure. Hence, we gradually modified the triage
protocol; now those who have the above‐mentioned epidemiologi-
cal histories (1‐4), or do not have contact history but have re-
spiratory symptoms and fever (temperature ≥ 37.3°C), will be
referred to fever clinic for further checkup. Patients who do not
have contact history or fever, but have respiratory symptoms, will
be referred to respiratory out‐patient department. Those who do
not have contact history or respiratory symptom, but present fever,
will be referred to emergency internal medicine department for
further checkup. Those who pass the screening (low‐risk patients)
are allowed to visit specialist out‐patient departments. In another
article written by specialists from Chengdu, Sichuan provenience,
they first screen patients through online clinic, those high‐risk pa-
tients will be directly referred to fever clinic through green channel,
and those who do not need urgent medical care will be re-
commended to postpone their visit or visit a non‐antiepidemic
hospital. In hospital, they also evaluate patients' symptoms first. If a
patient present fever or respiratory symptoms, their contact history
in past 14 days will be further investigated, if this patient reports
contact history, he/she will be assigned to high‐risk fever clinic, and
if contact history is denied, the patient will be assigned to low‐risk
fever clinic. For those who do not have such symptoms will be re-
ferred to other departments.26 In a hospital in Nanjing, the first
triage only includes temperature check, those who have a fever will
be further questioned with epidemiological history, those with both
fever and epidemiological history will be assigned to fever clinic,
those who only present fever will be refer to respiratory depart-
ment or other specialists, and if a patient does not have fever, he/
she will be allowed into other specialist department.27
During the stay in hospital, face mask is mandatory and will be
provided if necessary. Videos and broadcasts of instructions on hand
hygiene, seven‐step hand‐washing, coughing manner, safety distance,
the process of visiting doctors, and admission procedure will be
played in every waiting section. All nurses in charge of the patient
triage will require second‐level protection.
Standardized protection includes three levels:
• First level: regular medical face mask, white coat, medical rubber
gloves, and hand sanitizer.
| 735
• Second level: disposable cap, surgical mask (medical protective
respirator under certain circumstances), protective face shield or
goggles, protective clothing outside the work clothing (such as
white coat), medical rubber gloves, and hand sanitizer.
• Third level: disposable cap, protective face shield or positive
pressure headgear, goggles, medical protective respirator (N95),
disposable coverall protective clothing, medical rubber gloves, and
disposable shoe covers.
3.3 | Admission procedure for regular patients
In case 2 that we presented, the patient was not in an emergency
situation, yet she only underwent epidemiological evaluations but not
laboratory examination before admission. As a matter of fact, we
changed our admission requirements twice before we settled with our
current strategy. In the beginning, nonemergency patients who did not
have epidemiological history or related symptoms would be admitted
directly and those who did would be referred to fever clinic for further
checkups. Then, when the epidemic situation got more serious, blood
routine and chest CT were required before admission, those who had
abnormal results would be further tested with viral nucleic acid. In
early February, several cases with unknown origin were reported in
Shenzhen, and later on, we also learned that some of these patients
presented symptoms earlier than their spreader due to the wide‐
ranged latent period of SARS‐CoV‐2, making it harder to trace pa-
tient's contact history. As the return peak of Spring festival brought
back a lot of people with uncertain contact histories, the admission
procedure was modified to avoid potential missed diagnosis. Ad-
ditionally, during the peak of the epidemic, those whose treatment can
be postponed were advised to delay their appointment.
Once hospitalization is needed, the following procedures have to
be done before admission (Figure 2). Viral nucleic acid test (naso-
pharyngeal swab, reverse‐transcription PCR) is now mandatory and
free of charge, blood routine test is required, and CT scans are not
required for women with ongoing intrauterine pregnancy without
contact history and abnormal clinical symptoms but necessary for
other conditions.
Patients without any signs of infection can be admitted. For
those whose test results indicate some abnormalities, but the viral
nucleic acid test comes out negative, the following should be done.
First of all, thorough re‐evaluation of contact history, symptoms, and
body temperature will be examined. Based on the latest edition of
practice guideline issued by National Health Commission, the fol-
lowing criteria need to be taken into consideration to identify a
suspected case24:
• Contact history (four criteria mentioned in the above section).
• Fever or respiratory symptoms.
• Typical CT scan features.
• Typical blood routine test features: normal or reduced peripheral
blood leukocyte count and decreased lymphocyte count in early
stage of the disease.
736 | CHEN ET AL.

F I G U R E 2 Standardized procedure for admission. *Emergencies include but not restricted to suspected ectopic pregnancy with abnormal
vital signs, abnormal vaginal bleeding, hyperemesis gravidarum with metabolic disorder parturition, threatened preterm labor. COVID‐19,
coronavirus disease 2019; CT, computed tomography

If a patient has any of the four forms of contact history and at
least two of the three clinical signs or does not have any form of
contact history but has all three clinical signs, he/she will be suspected
of infection. Meanwhile, in cases of intrauterine pregnant women, CT
scans are not required for COVID‐19 screening before admission.
Thus, if a patient reports an epidemiological contact history or clinical
symptom, CT scans will be advised. Although radiation dose of chest
28
CT with abdominal protection was considered negligible, scans
should only be given with pregnant patient's consent after being fully
informed with the relative risks. After CT scans, the pregnant women
who are suspected of infection will be hospitalized in the appointed
isolated single‐bed ward and nonpregnant patients will be referred to
fever clinic for further diagnosis. It should be noted that generally
patients in the early stage of COVID‐19 present a distinct blood leu-
kocyte change,1 but in cases of pregnant women, the physical change
of blood cell component as pregnancy progresses should be taken into
account. It is also common phenomena that pregnant women do not
show typical clinical presentations in various diseases, and some
symptoms such as short breathing, fatigue, and bowel dysfunction may
be concealed by pregnancy. Hereby, we are extra cautious with any
risk factor when it comes to pregnant women.
According to some practice guidelines in the early stage of the
epidemic, if a patient is suspected of COVID‐19, laboratory exams in-
cluding influenza A virus, influenza B virus, Mycoplasma pneumoniae,
Chlamydia pneumoniae, respiratory syncytial virus, adenovirus, coxsack-
ievirus, and parainfluenza virus may be given first, and if the above-
mentioned infections are excluded, SARS‐CoV‐2 nucleic acid should be
tested.22,29 Nonetheless, as nucleic acid test kit production outnumbered
the suspected patients in mid‐February, we now directly prescribe
SARS‐CoV‐2 nucleic acid test. Other pathogens may be used for dif-
ferential diagnosis if the patient is tested negative for SARS‐CoV‐2.
Once viral nucleic acid is tested positive, a diagnosis will be con-
firmed, and the patient will be immediately informed, quarantined, and
transferred to appointed hospitals following “Transport Plan for
COVID‐19 cases (Trial)” issued by National Health Commission.30 Ad-
vice on referral of obstetric patients given by Liaoning provenience also
suggested that one obstetrician and one nurse are required to ac-
company the transport of pregnant patient. The ambulance should be
equipped with a Doppler stethoscope or a continuous electronic fetal
heart monitor. Equipment for delivery shall be provided if necessary.22
3.4 | Admission procedure for emergency patients
Emergencies such as suspected ectopic pregnancy, severe vaginal
bleeding without confirmed pregnancy, parturition, premature rupture
of membranes, fetal distress, vaginal bleeding during pregnancy, and
abnormal vital signs (except fever) may be referred directly to the
CHEN ET AL. | 737

in‐patient department of gynecology or obstetrics. In these cases,

nurses at in‐patient department are responsible for finishing epide-
miological evaluation, body temperature check, and sample acquiring.
Before the possibility of infection is ruled out, all medical perfor-
mances should be done following quarantine and protection instruc-
tions. It should be noted that in many cases of emergencies,
treatments need to be performed immediately regardless of the pa-
tients' infection status. In these cases, if the infection is diagnosed or
cannot be ruled out yet, the patients will be isolated in single‐bed ward
and if delivery or surgery is needed, delivery or operating room should
be informed first and the appointed delivery or operating room should
be used only. Aerosol‐generating procedures such as general an-
esthesia with tracheal intubation should be avoided in surgeries if
possible.31,32 During any medical performance given to suspected or
diagnosed patient, we use consumable medical material if possible and
all recyclable devices will be sterilized after having contact with such
patients and all medical and domestic waste are disposed of as in-
fectious waste. Standard third‐level protection is required for all staff
members who are going to have any sort of contact with these pa-
tients. After the surgery or delivery, the patient should be quarantined
in the appointed single‐bed ward, neonates will be quarantined in
neonatal intensive care unit and breastfeeding will be postponed till
the possibility of infection is eliminated or the infection is cured. If the
F I G U R E 3 Standardized procedure for newly discovered
diagnosis is confirmed, the patient should be transferred to appointed
high‐risk cases at in‐patient department. COVID‐19, coronavirus
hospitals after his/her condition is stabilized. disease 2019; CT, computed tomography

3.5 | Countermeasures for a newly discovered

high‐risk patient at in‐patient department
At in‐patient departments, temperature checkup three times a day is
mandatory for low‐risk patients, more frequent checkup may be given
according to actual conditions. If body temperature higher than 37.3°C
or respiratory symptom is observed or there is contact history to a
newly suspected/diagnosed case or a patient report previously con-
cealed risky contact histories, immediate actions (Figure 3) including a
warning to all staff members in the department, informing the patient
and his/her family about the situation while offering epidemiological
evaluation and self‐quarantine advice, quarantine in single‐bed ward,
blood routine test, and viral nucleic acid test should be taken. CT scans
should be given with fully informed consent for pregnant women. Then,
all results should be consulted by the appointed COVID‐19 expert. It
should be noted that patients and their family may panic during this
process, a thorough conversation that fully informs them about the
current situation, the possibility of other causes, and the counter-
measures that will be taken can avoid misunderstanding and
unnecessary panic.
4 | D I S C U S SI O N
With the rise in global attention, much has been done to better un-
derstand and control COVID‐19 from various perspectives.
Nonetheless, little has been mentioned regarding maternal health
care management. It has been well understood that the female body
changes drastically during pregnancy. Alterations in cellular im-
munity such as downregulation of lymphocyte proliferation and ac-
tivation are primarily aimed at adopting maternal immune tolerance
to fetus.33,34 Nonetheless, these changes also turn the host more
vulnerable and susceptible to pathogens. In addition, as the preg-
nancy progresses, the enlarging uterus leads to elevation of the
diaphragm, widening of the chest and thoracic cage, as well as edema
in the upper respiratory airway.9 These physical changes may add up
to the difficulty to clear secretions and foreign matters such as dust
and pathogens,34 which may increase the risk of infection and
accelerate the progression of the disease.
COVID‐19 shares very similar transmission routes and clinical
manifestations with SARS and MERS. Though the epidemiological
data with regard to pregnant women are currently lacking, some
specialists from Wuhan suggested that based on clinical observation,
COVID‐19 may result in rapid multiple organ failure and can be as
fatal as SARS. Hence, we further review both these diseases. In a
study that included 12 pregnant women infected by SARS‐CoV in
Hong Kong, 3 of whom passed away, 4 out of 7 who were infected in
the first trimester had spontaneous miscarriage, 4 out of 5 who
presented after 24 gestational week had preterm delivery, and 2 who
recovered before labor had intrauterine growth restriction.35
Despite the limited sample size, the results indicated higher fatality
738 | CHEN
rate in pregnant population and adverse potential obstetric out-
come.36 In a review that included 11 pregnant MERS patients, 3 died,
2 terminated their pregnancy prematurely due to severe maternal
respiratory failure, and 1 had intrauterine fetal death.37 No evidence
of in utero transmission was discovered in SARS or MERS,38 and
proof of vertical transmission has not been found as well. However,
there is a report of neonates being tested positive for SARS‐CoV‐2
after 30 hours of birth.39 Hence, compare to the potential adverse
outcome, the cost of effective preventive measures is much lower.
With regard to vertical transmission, no solid evidence has been
reported so far. In a research that included nine pregnant COVID‐19
patients who had a cesarean section, breast milk, amniotic fluid, and
umbilical cord blood were taken; all samples were tested negative for
SARS‐CoV‐2.40 In another study, a patient's breast milk along with
serum, urine, feces, amniotic fluid, umbilical cord blood, and placenta
samples were tested negative for SARS‐CoV‐2.41 A recent study
collected maternal breast milk, serum, cord blood, placental tissue,
amniotic fluid, vaginal swab, and newborn's nasopharyngeal swab at
or after delivery; all samples were tested negative.42 Despite the lack
of evidence of SARS‐CoV‐2 existing in breast milk, breastfeeding and
breast milk are not recommended for suspected and diagnosed pa-
tients due to the following reasons: (a) the limited data cannot rule
out the possibility of vertical transmission; (b) neonates or infants
should be separated from suspected or diagnosed patients due to the
strong infectivity of COVID‐19; (c) the virus may transfer to milk or
the milk bottle during the milking process, giving a chance of ex-
posure even without direct contact with the infected mother. A case
reported in 2004 suggested that antibodies to SARS‐CoV were de-
tected in maternal serum, cord blood, and breast milk.43 Whether
SARS‐CoV‐2 antibodies appear in cord blood, breast milk, and neo-
natal serum is yet to be known. If they do, whether the benefit of
these antibodies overcomes the risk of breastfeeding is also
questionable.
A recent epidemiological research conducted by the Chinese
Center for Disease Control and Prevention (CDC) revealed that by
11 February, a total of 3019 health care workers working in medical
facilities were infected.44 It was also reported in South Korea that in
a psychiatric department with 102 patients and staff, 99 were in-
fected. These alerted us on the risk of nosocomial infection and su-
perspreading event. Despite this risk, the high incidence and fatal
outcome of ectopic pregnancy,45 pregnancy complications such as
eclampsia,46 as well as congenital malformations caused by genetic or
chromosomal defects should not be neglected. Antenatal care during
pregnancy significantly reduces adverse maternal and fetal out-
comes.19,47 Thus, canceling these checkups to avoid COVID‐19 may
put pregnant women in a riskier position.
Isolation has been proven to be an effective way to control the
spread of COVID‐19 by the observation of the epidemic situation in
China as well as a mathematical model.48 Thus, although our patients
are advised to attend recommended checks on schedule, we are ob-
ligated to provide them a safer environment by separating regular,
high‐risk, suspected, and diagnosed patients with a well‐organized
managing system. In contrast to the outbreak of SARS in 2003, online
ET AL.
platforms are well developed nowadays. These applications enable us
to not only better inform, communicate with, and consult our patients,
but also answer their doubts, relieve their anxiety, and clear the panic
caused by rumors, which significantly reduces unnecessary hospital visit
without increasing the risk of complications. Given that 420 patients
were diagnosed by 11 March in Shenzhen and tens of cases were
diagnosed in our hospital, yet no nosocomial infection has occurred and
none of the pregnant woman registered in our hospital was reported to
be infected, this management should be effective to an extent; how-
ever, a mathematical model may be needed to quantify the effective-
ness of these methods. To the best of our knowledge, no pregnant
woman was infected in Shenzhen by far. Due to the lack of experience,
we are uncertain of the clinical features, disease progress, outcome, and
treatment of pregnant COVID‐19 patients. More work is needed to be
done to fill in these gaps in the future.
AC KNO WL EDG M EN TS
We'd like to thank everyone who fight the coronavirus, especially
who work on the frontline. This study was funded by Shenzhen
Municipal Health Commission, SZSM201812041; Clinical Research
Funding from Shenzhen Second People's Hospital/the First Affiliated
Hospital of Shenzhen University Health Science Center (No.
4001023); Shenzhen Science and Technology Innovation Committee,
JCYJ20170817172241688 and JCYJ20180228163529609.
CON F LI CT OF IN TE RES T S
The authors declare that there are no conflict of interests.
ORCI D
Yu Chen http://orcid.org/0000-0002-3647-2056
Zhi‐Ying Yu http://orcid.org/0000-0002-1533-1246
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How to cite this article: Chen Y, Li Z, Zhang Y‐Y, Zhao W‐H,
Yu Z‐Y. Maternal health care management during the
outbreak of coronavirus disease 2019. J Med Virol. 2020;92:
731–739. https://doi.org/10.1002/jmv.25787