Mumbai: The city of Mumbai has been seeing increased cases of COVID-19, and some hospitals and doctors are reporting more cases of pregnant women and children who have contracted the virus.
We speak with Ravindra Chittal, consultant paediatrician and neonatologist at Hinduja Hospital and Lilavati Hospital, and Kiran Coelho, head of department, obstetrics and gynaecology, at Lilavati Hospital to find out how this affects the overall problem in terms of capacity to respond and attend to these cases, and the treatment path that is being followed.
Dr Coelho, what kind of cases have you been seeing amongst pregnant women in the last month? Have you seen any changes?
KC: In my practice so far, I have not had any patient who is COVID positive. I practice at Khar Hinduja as well as Lilavati, and Surya Hospital. But with the numbers rising, we may get patients.
We have to test all pregnant women for COVID-19 within five days of their delivery. Normally, after the 32nd week, I am testing all my patients every 15 days, because they have to have a COVID-negative test; otherwise, they cannot deliver in the hospital. If they do come in an emergency without a COVID test, then we keep them in isolation, take care of them with complete protection (personal protective equipment), until their COVID test results come in. If they are COVID-negative, we continue with the delivery. If they are positive, then we send them to hospitals designated for deliveries of COVID-positive patients--in Mumbai, the municipal one is Nair Hospital, and the private hospitals are Nanavati Hospital and SL Raheja Hospital.
Dr Chittal, what has been your experience so far?
RC: We have not had any COVID-positive cases in the clinic. Everybody is following social distancing; they quarantine themselves voluntarily at home. The kind of class of people you get in Lilavati Hospital or Hinduja Hospital are from a more protected- or a gated-community.
We have had cases of our past patients, staying at a distance--like in Malad and Kandivali [in suburban Mumbai]--who have tested positive, because their parents tested positive and the child has to be quarantined. So far, none of the children have had any bad outcome. They become negative after eventual quarantining, and they do not have to be given any medication. In fact, as of now, there is no protocol medicine for COVID-positive symptomatic or asymptomatic children. It is basically the symptomatic medicines. We give azithromycin if there are respiratory symptoms. We cannot give hydroxychloroquine to children below 15 years of age, though some people have tried, sometimes with adverse side effects. We do not have a fixed protocol for children. If they have a respiratory infection, we treat with azithromycin, quarantine them, and manage them till they recover from the respiratory symptoms.
Children have robust lungs, thankfully. They do not have severe or bad outcomes like adults with comorbidities do. But, though children are known to pass the virus in the stools. They may be asymptomatic, but a COVID-positive child is equally of danger to the surrounding environment because they keep shedding [the virus]; even [among] neonates, there have been cases reported of delivery. Like Dr Kiran said, we have not had cases yet, but in the UK, they have had pregnant women--COVID-positive, symptomatic--delivering babies, and they gave [birth to] COVID positive babies. And this is not transmission during the delivery. This is vertical transmission--they are caesarean sections and the babies tested positive; of course, with a good outcome. But, to their dismay, they found that these babies keep on passing the virus in their stools. So that becomes a source of infection, even in neonates. We have to be very careful. The child is robust, asymptomatic, and survives but is a source of infection to everybody else in the house.
How do you gauge gastrointestinal symptoms in children? I am sure many parents want to know--because the children are the ones who go out and play, even now, and staying cooped up is a challenge.
RC: This infection is something that we have never been exposed to before. It is something different altogether. In fact, we keep changing our parameters of diagnosis, treatment, everything. Initially we said, fever is mandatory for COVID-positive child or an adult. Now, you can have COVID-positive without fever. You may or may not have respiratory symptoms. We said you have to do a CT scan for every person who is COVID positive, but the CT scan comes normal [in some cases]. Then we have GI symptoms--we have children with selectively GI symptoms (vomiting, severe abdominal pain) and the COVID test comes positive. We have had children with a tremendous amount of rashes in the bodies, we had children with thromboembolic/thrombotic phenomenon (blocking of blood vessels). So, this is the mother of all bugs. It is behaving differently in different situations--it may depend on the child’s own immunity, it may depend on the duration of the illness. So, only by a high index of suspicion can you pick up a COVID positive. Just by history, sudden onset of any symptom could be COVID positive.
Dr Coelho, how are you gearing up for potentially more cases among pregnant women? And what are you telling your current patients about how to take care and take the right precautions?
KC: Pregnant patients are absolutely petrified. With regard to antenatal visits, I think in the first trimester, if they just do an ultrasound at say 11-13 weeks, when we do early anomaly scan, then they can schedule the visit to the obstetrician at that point of time. Thereafter, [there is] another scan at 20 weeks; at that point, they can schedule a visit with the obstetrician. Otherwise, I encourage all patients to do video consultation with their obstetrician, so that they minimise travel to the hospital--unless, of course, they have other morbidities like diabetes and high blood pressure, etc. complicating the pregnancy, [in which case] they have to see the obstetrician more frequently.
Towards term, after the 32nd week, we would like to video consult with the patient every week until they go into term and do a last sonography around 37-38 weeks to ascertain the condition of the baby. A study has just come out last week, where they have studied 450 pregnant women and deliveries around the world, and found that there was a direct transmission of almost 9%; and premature labour (preterm labour), which was at 13.5%, is now at 26% in the COVID-positive patients and there is direct transmission. So, these are the problems that pregnant women would face.
As I said, we do the COVID testing, and the precautions they should take are the usual precautions: isolation, hand washing, wearing a mask whenever they go out, and proper hygiene as far as their cough and cold. Pregnant women are allowed to be tested for COVID; we give them a prescription and then can be tested. If they get flu-like symptoms--sore throat, cold, cough--then definitely, they should be tested. And isolation is so important--not going out to social gatherings, not going out of the house, keeping a safe distance from everyone in the house.
Most obstetricians have started video consultation with patients. I personally call up all my patients after the 32nd week, every week, and ask them how they are doing, give them advice on diet, exercise, their medication; give them tips on how to prevent getting infected, and then give them advice on when they should come to the hospital when they are in labour. We have a triaging system outside the hospital, where their temperature and blood pressure etc. are checked; and of course, only with a COVID-negative test only can they actually deliver in the hospital.
Normally, when a patient comes for delivery, they come with their mother, mother-in-law, husband and a whole retinue of people. But now, they are so apprehensive because only one birth attendant will be allowed at the time of delivery. Earlier, we were doing the COVID test of the birth attendant as well, but now they do not recommend it.
Hospitals in Mumbai are filling up, and that is placing a strain on all the other facilities. How are you placed, in terms of infrastructure, in the hospitals you are working in?
KC: Lilavati Hospital does have an isolation ward and a COVID ward, but that is not for pregnant women. So, for deliveries, we have to send them to the designated hospitals. We are not geared to conduct deliveries of patients who are COVID-positive, for various reasons. Number one, we cannot mix COVID-negative and COVID-positive patients; we do not have an isolated labour room; we do not have dedicated isolated nurses; and it is the government’s directive to send COVID-positive pregnant patients to designated hospitals.
Since there is a surge in cases, are you worried that it might start affecting more pregnant women? In that case, how difficult does that make life for you?
KC: Yes, the numbers are increasing. But as I said, in the private hospitals, the patients are not exposed as much. They are all maintaining their isolation; they are not going out in public; they are wearing masks and they are very particular. So, the chances of them getting infected, at least in my private patient population, is a little less. The numbers are increasing in all the areas--unfortunately--where isolation, staying at home is not possible. [When] a whole lot of people [stay] in one room etc., the chances of them getting infected are much more.
Dr Chittal, for children, you said that the index of suspicion should be high, and this a rapidly evolving disease--I was reading about the Kawasaki syndrome, as reported in the US, just a couple of days ago, where children are turning up with inflammatory shock syndrome; it is all inexplicable, difficult to pin down and understand. What would you recommend to parents at this point of time?
RC: It is helping, but it is also causing a lot of panic. To some extent, anxiety is good because it keeps the children inside the house. But it is very difficult to sustain indoor activity for children. Children need to go out, and that becomes challenging for the parents. They need to mix with friends next door; it is very challenging, but it is important also that they do not intermingle.
The second challenge that we paediatricians face is immunisation. We need to complete certain mandatory immunisations which are mandatory--such as polio, diphtheria-pertussis/whooping cough-tetanus (DPT), Hepatitis. The vaccine to be given at six weeks can be delayed by two weeks. The vaccine to be given at 14 weeks can be delayed by 10 weeks. But then, there is a circular from Johns Hopkins Institute that the mandatory vaccinations (below one year) have to be completed. So, we have started vaccinating patients. But we have to have a triage; we cannot allow vaccination babies to mix with sick babies.
In the clinic that I run, we do not see children with fever in the clinic. We have a fever scanner. If the child has a history of fever, he has to come with a COVID-19-negative report, only then will he be allowed inside. Only one attendant is allowed per child. We allow patients after a gap of every 15 minutes. We have to have a hand sanitiser, parents should have a mask, the child need not have a mask. And we are strictly following social distancing. All the same, the risk of exposing the child coming out, in a vehicle, maybe with a driver, we are not so sure that the child may not be likely infected outside. So, there is a real risk. But we have to finish vaccinating primary vaccines--for vaccine-preventable diseases. What can be delayed are the boosters--the Hepatitis A vaccine, chicken pox vaccine, (boosters are to be given between 18-24 months), or even the typhoid vaccine. But we cannot delay polio, DPT, hepatitis and pneumococcal vaccines; we need to finish those, at a risk. But if we follow the triage strictly, we can allow this to happen.
What about mental health? I know that is not what you are treating, but are you getting reports of how children are affected by this and if so, what should parents do?
RC: Believe me, I am dealing more with mental illness than physical illness. Physical illnesses are surprisingly low, because they are eating safe food, they are in a safe environment inside the house, they are not going to school, play school, nursery or day-care centers. So, the chances of transmitting infection are less, they are relatively healthy at home. But they are confined to a place. Many children have started bed-wetting, many children are constipated, many do not want to take medicines. There are simply throwing temper tantrums. And parents are at their wits’ end as to how to keep their own sanity and the child’s sanity. And it is going to be pretty challenging as the lockdown is extended more and more. To some extent we are losing our sanity, we have stopped putting on televisions, because you only get to know the increasing numbers. And children are not immune to this. They are definitely affected by the anxiety that parents transmit to them.
Dr Coelho, are you dealing with overanxious patients? How are you dealing with them and counselling them?
KC: Absolutely. As it is, during pregnancy every woman is anxious; especially those who are having their first babies. And now, it is magnified to the power of infinity, because there are so many apprehensions—whether they will get the infection, whether they will be in isolation, whether they are allowed a birth attendant, whether they will be able to manage, whether they will have a c-section or normal delivery (we prefer normal delivery, of course).
During pregnancy also, they are not getting the adequate exercise that they should. There are a lot of online prenatal exercises, which are available, and I share with all my patients. So, they can remain physically active during the pregnancy and be more prepared. But definitely, anxiety levels are tremendous. I have had patients with panic attacks. In my consulting room the other day, I had a patient who had come with 170/120 blood pressure, out of sheer anxiety, and we had to admit her, and she was almost about to get convulsions--something that we do not see normally in a patient with regular antenatal checkup.
Pregnancy yoga, meditation, frequent consultation with the obstetrician and online prenatal exercise are definitely recommended.
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