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REVIEW ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 2  |  Page : 73-81

Challenges in the management of corona virus in pregnancy in low resource countries


Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Submission06-May-2020
Date of Decision11-May-2020
Date of Acceptance27-May-2020
Date of Web Publication10-Jul-2020

Correspondence Address:
Abubakar Panti Abubakar
Department of Obstetrics and Gynaecology Usmanu Danfodiyo University/Usmanu Danfodiyo Teaching Hospital, Sokoto
Nigeria
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DOI: 10.4103/1319-8491.289357

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  Abstract 


Background: Coronavirus disease-19 (COVID-19) is a potentially lethal infection caused by severe acute respiratory syndrome. Pregnancy is a state of partial immune suppression, which makes pregnant women more vulnerable to viral infections. COVID-19 pandemic presents many challenges in when it coexists with pregnancy in resource-poor countries with background ignorance and deficient health infrastructure. Materials and Methods: A literature search for studies on COVID-19 was performed using Google Scholar search database, PubMed, Medline, and ScienceDirect. The bibliographies of included studies were also searched for additional references. About 85 articles were identified. Twenty-five articles were considered suitable for review. Results: An extensive review of management of COVID-19 in pregnancy and challenges confronting its management in resource-poor countries was presented. These challenges included poor health infrastructure, poor testing capacity, and nonadherence or impracticable preventive measures including physical distancing, hand hygiene, inadequate personal protective equipment, and stigmatization. Specific challenges related to pregnancy were availability of blood and blood products, labor management, operative deliveries, and postdelivery management. Conclusions: Current evidence suggests that its pathogenesis, clinical manifestations, and management are influenced by pregnancy. The outcomes of pregnancy and COVID-19 are negatively influenced by similar problems of ignorance, poverty, and deficient health infrastructure. COVID-19, therefore, has the potential for worsening maternal mortality in low-resource nations.

Keywords: Challenges, coronavirus, pregnancy, resource-poor countries


How to cite this article:
Abubakar AP, Rabiu AF. Challenges in the management of corona virus in pregnancy in low resource countries. Sahel Med J 2020;23:73-81

How to cite this URL:
Abubakar AP, Rabiu AF. Challenges in the management of corona virus in pregnancy in low resource countries. Sahel Med J [serial online] 2020 [cited 2020 Sep 30];23:73-81. Available from: http://www.smjonline.org/text.asp?2020/23/2/73/289357




  Introduction Top


On January 30, 2020, the World Health Organization (WHO) declared COVID-19 as a public health emergency of international concern.[1] Subsequently, on March 11, 2020, the world received a shocking but anticipated declaration of the COVID-19 by who as a pandemic.[1] As at that time, there were 118,000 cases in 114 countries and 4291 mortalities. There are over 210 countries with a total of 2,436,119 cases, 1,631,953 active cases, and 166,759 fatality cases (case fatality ratio [CFR]: 6.23%), and 6,374,077 (23.70%) have recovered as on April 20, 2020.[2]

Up until April 15, 2020, 45 (96%) out of the 47 member states of the WHO African region have reported COVID-19 cases. Comoros and Lesotho are the only member states with no reported cases to date.[3] As of April 14, 2020, there is a cumulative case of 10,759 in Africa, with 520 deaths (CFR: 4.8%). South Africa has the highest number of cases in the African region (2415 cases and CFR of 1.1%).[3] There are 34 states and Federal Capital Territory that have reported positive cases of COVID-19. So far Nigeria has collected and tested 8003 samples, 627 have been confirmed positive and 22 fatalities. The case fatality ratio of 3%.[4] Lagos state remains the epicenter of the virus.[4]

COVID-19 in pregnancy poses peculiar challenges both physiologically and pathologically. Pregnancy is an immune compromised and prothrombotic state. COVID-19 symptoms may deteriorate fast and early and easy access to care is needed to reduce risk to the fetus and mother.


  Materials and Methods Top


A literature search for studies on COVID-19 was performed using Google Scholar search data base, PubMed, Medline, and ScienceDirect. The bibliographies of included studies were also searched for additional references. About 85 articles were identified, and after the elimination of unrelated articles to the subject matter, 25 related articles were available for the review. The discussion on the challenges was drawn from observed challenges in Nigeria, webinar interactions with colleagues and expert opinions.


  Epidemiology Top


Geographic distribution

The coronavirus disease-2019 (COVID-19) is an emerging disease caused by a strain of coronavirus severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2).[5] It was first discovered in Wuhan, in Hubei Province, China, where high incidence of pneumonia in humans that has not been previously identified was observed in December 2019.[5] Since then, it has spread all over the world. The WHO announced a standard nomenclature COVID-19 for this novel coronavirus pneumonia on February 11, 2020.[5]

Virology

The International Committee on Taxonomy of Viruses named this novel coronavirus as SARS-CoV-2.[6] It is a single-stranded (positive sense), spherical, enveloped RNA virus. The virus particle has a diameter of 60–100 nm. It shares the same family with SARS and the Middle East respiratory syndrome (MERS). The coronaviruses are genotypically and serologically divided into four subfamilies: α, β, γ, and δ-coronavirus. Human coronavirus infections are caused by α- and β-coronaviruses.[7] Genome-wide phylogenetic analysis indicates that SARS-CoV-2 shares 79.5% and 50% sequence identity to SARS-CoV and MERS coronavirus, respectively.[7] However, there is 94.6% sequence identity between the seven conserved replicase domain ORF1ab of SARS-COV2 and SARS COV, and less than 90% sequence identity between those of SARS-CoV-2 and other β-CoVs, implying that SARS-CoV-2 belongs to the lineage B (sarbecovirus) of β-CoVs.[7] SARS-CoV-2 can be inactivated by ultraviolet or heated at 56°C for 30 min and also sensitive to most disinfectants such as diethyl ether, 75% ethanol, chlorine, peracetic acid, and chloroform.[7]

Pathogenesis

The COVID-19 utilizes the angiotensin-converting enzyme 2 (ACE2) receptors to gain access into the cell.[7] The ACE2 is a type 1 membrane protein expressed in organs such as the heart, lungs, kidney, and gastrointestinal system.[7] The full-length ACE2 consists of an N-terminal peptidase domain and a C terminal collectrin-like domain that ends with a single transmembrane helix and an ~40-residue intracellular segment. This provides the virus binding terminals with the S protein of COVID-19 m, allowing viral particles entry into the host cell and replication.[6],[7]

Transmission

COVID-19 is spread via droplets following cough, sneezing, or talking from an infected person to a susceptible individual within 2 m of the infected person.[4] It can also be transmitted via fomites with a contaminated hand on to a mucosal surface, the mouth, eyes, and nose.[4] An infected person can transmit the virus 2 days before the onset of symptoms as such asymptomatic individuals can be infectious.[8] Serious morbidity and mortality as a result of COVID-19 infection is substantial among frail, elderly patients, and patients with comorbidities such as diabetes mellitus, hypertension, chronic lung disease, other cardiovascular diseases, smoking, obesity, and the immunocompromised.[9]


  Effect of Pregnancy on Pathogenesis of Coronavirus Disease-19 Top


Pregnancy is a state of partial immune suppression, which makes pregnant women more vulnerable to viral infections, including COVID-19.[5] The lymphocytes produced cytokines, which regulates immunity and inflammation. T helper type 1 cytokines including gamma interferon (IFN), interleukin (IL)-1α, IL-1 β, IL-6, and IL-12 are microbicidal and pro-inflammatory,[8] while T helper type 2 (Th2-type 2) cytokines comprising IL-4, IL-10, IL-13, and transforming growth have anti-inflammatory effects.[5] In pregnancy, there is a change in cell-mediated immunity causing a physiological shift toward Th2 dominance, which contributes to overall infectious morbidity by increasing maternal susceptibility to intracellular pathogens such as COVID-19.[8] This immune response makes the severity of infection with different strains of the coronavirus more severe in pregnancy. Infection with SARS-CoV shows preferential activation of Th2-type 1 causing profound inflammation and fibrosis of the lungs.[8]


  Clinical Features of Coronavirus Disease-19 and Effects of Pregnancy Top


Different studies, case series, retrospective studies, and systematic analysis reported different symptom combinations and frequency of occurrence.[8],[9],[10],[11],[12],[13],[14],[15] Some of the symptoms compatible with COVID-19 infection are fever, cough, and difficulty in breathing. Other symptoms include headache, anosmia, myalgia, sore throat, malaise, and gastrointestinal symptoms.[16],[17] Tachycardia, tachypnea, and SpO2% may be low. Auscultation can be normal. Majority of cases (80%) are asymptomatic or present with mild symptoms, while 15% will present with mild-to-moderate symptoms requiring oxygen, and 5% will be critically ill requiring mechanical ventilation support.[7] Recovery occurs within 2 weeks for mild and 3–6 weeks for severe disease.[7]

Effects of pregnancy on the diagnosis of coronavirus disease-19

Therefore, the COVID-19 pandemic may have serious consequences for pregnant women and fetuses [9] and they represent high-risk population. This is particularly so when the cardiorespiratory system is affected. In late pregnancy, about 1/5th of pregnant women will present with gestational rhinitis because of estrogen-mediated hyperemia of the nasopharynx.[5] In pregnancy state, the physiological changes in the respiratory system is one such that it exacerbates the respiratory symptoms due to infection with COVID 19. These physiological changes include; congestion of the upper and lower airways due to the effect of estrogens, physiological dyspnoea as a result of increased oxygen demand, physiological or dilutional anaemia and increased metabolism. There is therefore the possibility of overdiagnosis of suspected COVID-19 or late diagnosis as COVID-19 symptoms may be misconstrued for physiological changes in pregnancy. In addition, other physiological changes in pregnancy occurring in the respiratory system can make symptoms due to COVID 19 more severe. These adaptations include; a steady declined in the functional respiratory capacity, expiratory volume and residual volume. All these cumulate into reduced total lung capacity, predisposing infected pregnant women to more hypoxaemia and respiratory failure. These changes may predispose to accentuate hypoxemia and respiratory failure in pregnant women with COVID-19 rapidly.[5]


  Laboratory Diagnosis of Covid and Implications for Pregnancy Top


The gold standard for the diagnosis of COVID-19 is a real-time reverse transcriptase polymerase chain reaction (RT-PCR), which has high sensitivity and specificity. Samples can be taken from the upper and lower respiratory tract, nasopharynx, oropharynx, saliva, urine, and stool.[5] The test utilizes specific primers and probes that target the RNA-dependent RNA polymerase (RdRp), envelope, and nucleocapsid genes of SARS-CoV-2, among which the RdRp assay has the highest analytical sensitivity (3.8 RNA copies/reaction at 95% detection probability).[5] As this test utilizes the viral DNA amplification and quantification, viral load estimation seems theoretically possible. However, this may require validation and internal control.[5]

The limitations of RT-PCR testing include the need for a biosafety level-2 facility, a requirement for kits with specific reagents and primers, the need to maintain a cold chain (as the specimens require storage at 2°C–8°C), and the use of strict, validated protocols for testing.[5] Consequently, countries with resource limitations may not be able to afford RT-PCR-based test.[5] Furthermore, a negative result does not necessarily always exclude COVID-19.[5] Other tests are antibody-based tests which have poor sensitivity and specificity.[5] Antibody-based tests may be negative during the window period.

Ancilliary tests: Radiological evidence using computed tomograohy (CT) of the chest have been found useful in diagnosing viral pneumonia due to COVID -19 in majority of pregnant women.[10] The predominant findings are peripheral airspace shadowing on a plain chest radiograph and bilateral, multilobar ground-glass opacities or consolidation on CT scan of the chest. These features are nonspecific and appear to be similar in pregnancy.[5] Using RT-PCR as a reference, the sensitivity, specificity, positive predictive value, and negative predictive value of a CT chest in diagnosing COVID-19 in China were 97%, 25%, 65%, and 83%, respectively.

Concerns regarding the teratogenic effects of ionizing radiation on the fetus following CT scan are reduced. This is because reassuringly, the fetal radiation dose for a routine CT chest is 0.03 mGy, and exposure of doses <50 mGy is not associated with an increased risk of fetal anomalies or pregnancy loss.[5] Although intravenous iodinated contrast media cross the placenta, studies have not demonstrated teratogenicity or thyroid dysfunction in the newborn. The risk of the fetus being exposed to radiation is hence minimal.[5],[6],[10]

Some scoring systems have been developed to assess the severity of lung affectation based on the lung lobe involvement. The system is as follows: none (0%) has a score of 1, minimal (1%–25%) score of 1, mild (26%–50%) score of 2, moderate (51%–70%) score of 3, and severe (71%–100%) score of 4.[10] Other methods have been tried for diagnosis; however, they are not yet verified. These methods include combination of immunochromatography, colloidal gold, and other technologies, relevant detection reagents. Recently, CRISPR/Cas13-based SHERLOCK technology was released to detect SARS-CoV-2.[4] However, this CRISPR/Cas13 system remains to be verified because it has not been tested on clinical samples from COVID-19 patients.[4] Complete blood count may show lymphopenia, and there may be elevated C-reactive protein, erythrocyte sedimentation rate, and ferritin.


  Effect of Coronavirus Disease-19 on Pregnancy Outcome Top


There are currently no data, suggesting an increased risk of miscarriage or early pregnancy loss in COVID-19. As there is no evidence of intrauterine fetal infection with COVID-19, although there was evidence of fetal compromise and prelabor preterm rupture of the membranes, it is therefore currently considered unlikely that there will be congenital effects of the virus on fetal development.[15],[16]

Based on reported cases, all neonates with confirmed COVID-19 were infected after birth via cough of mother or other relatives or through the infected environment and had an average time of symptom manifestation between 5 and 17 days after birth.[16] The most common symptoms of COVID-19 in infants were tachypnea, milk regurgitation, vomiting, cough, fever, pneumothorax, liver disorders, thrombocytopenia, and pulmonary changes in chest CT scan.[17],[18] Protracted respiratory compromise increases the risk of fetal growth restriction due to maternal hypoxia which drives the release of potent vasoconstrictors such as endothelin-1 and hypoxia-inducible factor, resulting in placental hypoperfusion and reduced oxygen delivery to the fetus. Intrauterine growth restriction complicates approximately 10% of pregnancies with COVID-19.[5]

COVID-19 outcomes for pregnant women appear more promising compared to SARS and MERS.[5] Pooled data reveal a case fatality rate of 0%, 18%, and 25% for COVID-19, SARS, and MERS, respectively. This difference in the case fatality rate is a result of progressive respiratory failure and severe sepsis commonly seen with infection with SARS and MERS. This is not surprising, given the predisposition to superimposed bacterial infections due to direct mucosal injury, dysregulation of immune responses, and alterations to the respiratory microbiome after viral pneumonia. Postnatal maternal deterioration can still occur, necessitating continued monitoring.[5]


  Management of Coronavirus Disease-19 in Pregnancy Top


Isolation, classification of disease, and oxygen therapy

Pregnant women suspected of COVID-19 should be isolated and investigated. Those confirmed with infection should be promptly admitted to a negative pressure isolation ward equipped with adequate facilities and multidisciplinary expertise to manage critically ill obstetric patients.[5],[6],[15] They should be triaged into mild (symptomatic patient with stable vital signs), severe (respiration rate ≥30/min, resting SaO2 ≤93%, arterial blood oxygen partial pressure (PaO2)/oxygen concentration ≤300 mmHg), or critical (shock with organ failure, respiratory failure requiring mechanical ventilation or refractory hypoxemia requiring extracorporal membrane oxygenation [ECMO]) categories based on clinical evaluation and managed by a multidisciplinary team of midwife, obstetrician, specialist in intensive care medicine, microbiologist, anesthetist, and neonatologist.[5] All medical staff caring for COVID-19 patients should use personal protective equipment including gown, N95 masks, goggles, and gloves.[5],[6],[7],[19]

Chemotherapeutic agents (antiviral)

All therapeutic options against COVID-19 infection in pregnancy are still under investigations. The WHO advised caution when using these agents.[2] Some of the agents being tested include Type I IFNs, which are antiviral cytokines that induce a large range of proteins that can impair viral replication in targeted cells. Previous studies have reported that IFN-β was superior against SARS-CoV compared to IFN-α. Synergistic effects of leukocytic IFN-α with ribavirin and IFN-β with ribavirin against SARS-CoV were demonstrated in vitro.[4],[7] Ribavirin is teratogenic and can induce miscarriage, craniofacial, and limb defects in the embryos of pregnant mice exposed to doses exceeding 25 mg/kg and should be avoided, especially in early pregnancy.[5] It has been reported that the use of lopinavir/ritonavir with ribavirin has a good therapeutic effect in SARS and MERS.[5] Lopinavir/ritonavir has been recommended for clinical trial for COVID-19.[4] Remdesivir was used in the treatment of the first COVID-19 patient in the United States and was shown to have antiviral activity against SARS-CoV-2 in vitro. Remdesivir is undergoing several clinical trials, one of which is by the National Institute of Allergy and Infectious Disease whose preliminary data released showed that COVID-19 patients who were given remdesivir recovered faster than those who received placebo.[20] Arbidol, a broad-spectrum antiviral compound, is able to block viral fusion against influenza viruses. Arbidol and its derivative, arbidol mesylate, have been reported to have antiviral activity against SARS-CoV in vitro.[5] The antiviral activity of arbidol against SARS-CoV-2 has been confirmedin vitro and recommended for clinical trial.[4]

Chloroquine and hydroxychloroquine

Chloroquine has many interesting biochemical properties including antiviral effect. It has been found to be a potent inhibitor of SARS-CoV through interfering with ACE2.[4] Chloroquine can effectively inhibit SARS-CoV-2in vitro and is recommended for clinical control of viral replication.[5] It is equally safe in pregnancy.[4],[8] It has been shown to block coronavirus infection by increasing the endosomal pH required for cell fusion and by interrupting the glycosylation of cellular receptors of SARS-CoV in cell culture.[5] Multicenter clinical trials across China have demonstrated that the drug appears effective in accelerating the clinical, radiological, and serological resolution of COVID-19.[4],[21] Although chloroquine and its metabolites cross the placenta,[5] it may be safely used in all trimesters of pregnancy with no increased risk of adverse perinatal outcomes. However, it is worthwhile noting that chloroquine is a drug with a large volume of distribution, and pharmacokinetic studies have shown significantly lower plasma drug concentrations in pregnancy, which suggests the need for a higher dose in COVID-19 (at least 500 mg twice daily).[5],[7],[22] Some of the side effects of high-dose chloroquine include systolic hypotension and abnormal electrocardiogram tracing.[5]

Zinc and chloroquine

Zinc is an essential element for growth and development and maintenance of immune function.[23] Chloroquine has been reported to act as a zinc ionophore, thereby allowing extracellular zinc to enter inside the cell, and inhibits viral RNA-dependent polymerase [24] which has been suggested as a potential mechanism of action on COVID-19. Zinc inhibits the replication of SARS-CoV in infected cells.[25] Chloroquine enhances zinc uptake by cells in a concentration-dependent manner.[24] Chloroquine has also been documented to increase zinc absorption [24] and combination of the two-drug regimen in COVID-19 infection.

Based on the virology of SARS-CoV-2, blocking the binding of S protein to ACE2 is important for the treatment of virus infection.[22] ACE2 is an important component of the renin-angiotensin system (RAS). RAS inhibitors, ACE inhibitor, and AT1R may be potential therapeutic tools for COVID-19.[22] In addition, intravenous transplantation of ACE2-mesenchymal stem cells, blocking of FcR viruses with intravenous immunoglobulin, and systemic anti-inflammatory drugs to reduce cytokine storm are also potential therapeutic strategies for severe COVID-19.[22] However, most of these drugs are not safe in pregnancy; hence, caution is applied when considering these drugs.

Convalescent plasma

Recently, convalescent plasma has been widely recommended to be used for COVID-19, but the effect of convalescent plasma cannot be discerned from the effects of patient comorbidities, stage of illness, or effect of other treatments.[26]

Supportive treatment

Other supportive measures include adequate rest, hydration, proper nutrition, supplemental oxygen, fluid, and electrolyte balance. In severe or critical cases, intubation and mechanical ventilation or even ECMO may be required to maintain oxygenation.[6] Antibiotics can be given in presence or suspicion of superimposed bacterial infection. Corticosteroid is not recommended routinely because it appears to delay viral clearance with no survival benefit.[5] Although neither hydrocortisone nor methylprednisolone readily crosses the placenta, prolonged exposure predisposes to maternal hyperglycemia which may cause immunosuppressive and sustains the replication of respiratory viruses within pulmonary epithelial cells. It may however be administered to achieve fetal lung maturity.[5] It has also been used in severe cases of dyspnea and hypoxemia for 3–5 days in an attempt to ameliorate lung inflammation and prevent acute respiratory distress syndrome (ARDS).[6] In preterm delivery for obstetric or medical indications, the decision to use corticosteroids to accelerate fetal maturity and minimize peripartum complications should be individualized. Good obstetric practice should prevail and urgent delivery should not be delayed.[5] The current standard of care should be employed in the management of pregnant women with complications of COVID-19, such as sepsis and ARDS.

High sequential organ failure assessment (SOFA) score and D-dimer levels >1 μg/mL on admission predict increased mortality in nonpregnant patients with COVID-19.[5] However, D-dimer levels are difficult to interpret as the values are usually raised in pregnancy, such that only 84%, 33%, and 1% of women in the first, second, and third trimesters, respectively, would have normal results based on conventional thresholds. The SOFA score should also be adjusted to reflect the influence of pregnancy on hemodynamics and renal blood flow, such as utilizing a creatinine level >1.02 mg/dL (instead of >1.20 mg/dL) to signify renal dysfunction.

Mechanical ventilation

In addition, mechanical ventilation requires achieving higher maternal oxygen (target PaO2 >70 mmHg instead of 55–80 mmHg) and lower carbon dioxide levels (target PaCO2 28–32 mmHg) to maintain placental perfusion and prevent fetal hypoxemia and acidosis.[5]

Delivery should be individualized based on the severity of the disease, gestational age, fetal condition, and other existing comorbidities such as preeclampsia, diabetes, and cardiac disease.[6],[12],[27] In mild and stable cases without fetal compromise that is responding to treatment, pregnancy may be continued to term under close surveillance. Regular monitoring of maternal vital signs such as temperature, pulse rate, blood pressure, respiration rate, and oxygen saturation should be done.[27] Other forms of surveillance include electrolytes and fluid balance, arterial blood gases, and acid-base status. Close fetal surveillance using ultrasound and cardiotocograph is recommended to assess fetal well-being.[13]

Management of labor and delivery

In critical cases, continuing pregnancy may endanger the safety of the mother and her fetus. Therefore, delivery should be considered even if the baby is premature.[5] Termination of pregnancy should be considered as an option before fetal viability is reached to reduce morbidity after careful consultation with the patient, her family, and an ethical board.[5] The mode of delivery is mainly determined by obstetric indications. Careful consideration should be given in regard to choice of anesthesia when a delivery by cesarean section is required. In two published reports from China involving a total of 18 pregnant women with COVID-19, all but two were delivered vaginally, and none of these neonates were infected by SARS-COV-2. As the evidence for vaginal shedding of virus and vertical transmission is lacking, vaginal delivery may be considered in stable patients.

Vertical transmission

Vertical transmission has not yet been confirmed, and samples from amniotic fluid, placenta, cord blood, neonatal swaps, and breast milk have all been confirmed negative among pregnant women with diagnosed COVID-19 and their neonates.[6],[17] Therefore, early cord clamping and temporary separation of the newborn for at least 2 weeks is recommended to minimize the risk of viral transmission by avoiding longer, close contact with the infected mother.[6] The neonate should be cared for in an isolation ward and carefully monitored for any signs of infection. During this period, direct breast-feeding is not recommended. A possible option is for the mother to pump her breast milk, which can be fed to the baby by a healthy caregiver.[26]


  Prevention of Coronavirus Disease-19 Top


Vaccination probably offers the best option for COVID-19 control. Epitopes, mRNA, and S protein-RBD structure-based vaccines have been widely proposed.[22] Rapid reconstruction of SARS-CoV-2 using a synthetic genomics platform has been reported, and this technical advance is helpful for vaccine development.[22] Human ACE2 transgenic mouse and rhesus monkey models of COVID-19 have been well established for vaccine development, and some SARS-CoV-2 vaccines are already under clinical trial.[22] Currently, there are no approved vaccines for the prevention of COVID-19, although several are under development but will not be available for some time. An open-label, phase 1 clinical trial in nonpregnant women and men evaluating a candidate vaccine, mRNA-1273, led by the U. S. National Institutes of Health has commenced recruitment on March 16, 2020 (ClinicalTrials.gov number NCT 04283461). The safety and immunogenicity of this lipid nanoparticle-encapsulated mRNA-based vaccine in pregnancy is, at present, unknown.[5]


  Challenges in the Management of Covid-19 in Resource-Poor Countries Top


The challenges of the management of COVID-19 in pregnancy in poor resource settings will be discussed under two broad headings as general challenges and specific challenges.


  Deficient Health Infrastructure Top


The current pandemic has brought to surface the weaknesses of our governments in health-care delivery system.[28] Poor state of health infrastructural facility in most resource-poor settings is largely due to poor and low budgetary allocation in most countries. Nigeria for example has just about 3.9% of its total budget to the health sector in 2020,[29] which may lead to the unavailability of state of art equipment, instruments, and deficit in consumables.


  Poor Testing Capacity Top


The testing capacity of COVID-19 in most developing countries is low.[30] There are delays between sample collection for testing and release of results, some results were delayed for about 5 days at the initial phase of the pandemic thereby, delaying isolation and treatment which may lead to further spread of the disease and mortality.[30] In Nigeria for example, samples were transported across several kilometers for testing. These difficulties were not unconnected with the fact that most developing countries are dependent on others for test kits.


  Limitations in Observing Physical Distancing and Hand Sanitization Top


Observing physical distance of at least 2 m with one another can prevent the spread of COVID-19. However, this is not practicable in resource-poor countries, especially those that reside in slums and crowded homes with large families. Furthermore, local markets and motor parks are overcrowded, thereby mitigating the implementation of social or physical distancing. Lockdown is also difficult to implement as most people in the low resource nations are daily paid self-employed workers and there are no social services. Hand hygiene is difficult to implement because there is no tap running water. Hand sanitizers are either not available or affordable. There is also issue of substandard hand sanitizers.


  Lack of Personal Protective Equipment Top


There is inadequate provision of personal protective equipment (PPE) to health workers putting them at risk of infection. Most of the PPE are imported. The PPE are ideally supposed to be used once and discarded, but usually disinfected and reused severally with attendant risk because of scarcity.[28] There is also inadequate training of the health workers as regards safely donning (putting on) and doffing (taking off) of the PPE. Most health professionals may get contaminated during doffing. Masks are difficult to get especially for the health-care professionals who are the front liners. One may be amazed to see politicians wearing and wasting N-95 mask on screen, but health-care providers may be wearing cotton made mask not even surgical mask. Therefore, improper channeling of some of the PPE is a serious challenge.


  Stigmatization Top


One unfortunate challenge in the management of COVID-19 patients in resource-poor countries is stigma. When a patient is managed and discharged for COVID -19, they are confronted with stigmatization at various levels ranging from the family, hospital, work place and the community. Stigmatization may lead to patients not wanting to get tested for COVID-19 which may lead to increase transmission.

Family

According to our discussion with COVID – 19 survivors, the stigmatization at the family level was more traumatizing. To integrate back to the family may not be smooth. One of my patients said she is yet to be intimate with her husband despite her discharge from the hospital for almost a month. A patient said his brothers could not check on his family while he was undergoing treatment because of phobia of COVID-19 and are still boycotting his house even after being declared negative twice.

Hospital

The stigmatization in the hospital could be by health workers toward the patient or the patients toward the health worker. The one we experience was the later. Patients who were previously being managed by a particular physician avoids the physicians because they had COVID- 19. Private Hospitals where Positive COVID- 19 cases were diagnosed, managed or died lost patronage.

Workplace

It may not be surprising for a COVID-19 survivor to be relieved of her job by her employer. There could be stigmatization among colleagues in the work place toward a COVID-19 survivor.

Community

Some COVID-19 survivors are still yet to be completely integrated back into the community despite various enlightenment by the NCDC that COVID-19 survivors are safe and not infected.[30] A survivor lamented that her next door neighbor prevented her kids from mingling with hers because she survived COVID- 19 and this can escalate to the larger society.


  Poor Fumigation Services Top


Fumigation of infected areas and even the community as practiced in develop countries was to mitigate fomite transmission of COVID-19. However, in most resource-poor countries, fumigation is inadequate.


  Specific Challenges Top


There are specific challenges in the management of COVID -19 positive pregnant women in low resource countries which includes: co-existing diseases in pregnancy with COVID-19, blood and blood products, operative deliveries and post -natal management.


  to Co-Existing Diseases in Pregnancy With Covid-19 Top


In developing countries, pregnant women may be anemic, mostly due to malaria, hook worm infestation, and hemoglobinopathies.[31] In Abeokuta, the prevalence of malaria at booking was 50.9% out of which 69% of them were anemic.[32] Zinc deficiency is strikingly common affecting up to a quarter of the population in developing countries.[23]


  Blood and Blood Products Top


The demand for blood and blood products like fresh frozen plasma is usually in high demand in obstetrics to manage obstetric hemorrhage in low-resource nations because of frequent underlying anemia and obstetric complications.[31],[32] As COVID-19 pandemic progresses, there may be shortage of these products because of “lock down.”


  Operative Deliveries Top


Some COVID-19-positive patients may require operative deliveries like cesarean section. There may be a challenge in arranging a dedicated theatre space, machine, equipment's and staffs amidst shortages.


  Postnatal Management Top


Postvaginal and postoperative deliveries pose another level of challenge. Caregivers cannot seat by the patient's bedside as usual. Bonding with the baby is limited, as the baby has to be placed 2 m away from the mother depending on her clinical status. Breast milk expression by breast pump is advised in moderate to critical cases, but mother may breastfeed wearing her N-95 mask in mild cases. Some patients may not be able to afford the breast pump leading to other issues of lack of aseptic handling of baby feeding with its sequelae.


  Conclusions Top


COVID-19 is an emerging disease. Current evidence suggests that its pathogenesis, clinical manifestations, and management are influenced by pregnancy. The outcomes of pregnancy and COVID-19 are negatively influenced by similar problems of ignorance, poverty, and deficient health infrastructure. COVID-19, therefore, has the potential for worsening maternal mortality in low-resource nations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
   Abstract
  Introduction
   Materials and Me...
  Epidemiology
   Effect of Pregna...
   Clinical Feature...
   Laboratory Diagn...
   Effect of Corona...
   Management of Co...
   Prevention of Co...
   Challenges in th...
   Deficient Health...
   Poor Testing Cap...
   Limitations in O...
   Lack of Personal...
  Stigmatization
   Poor Fumigation ...
  Specific Challenges
   to Co-Existing D...
   Blood and Blood ...
  Operative Deliveries
  Postnatal Management
  Conclusions
   References

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