Follow-up for pregnant women during the COVID-19 pandemic: French national authority for health recommendations

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Guidelines

Follow-up

for

pregnant

women

during

the

COVID-19

pandemic:

French

national

authority

for

health

recommendations

ARTICLE INFO

Articlehistory:

Availableonline11May2020

ABSTRACT

Introduction:Inthecontextofthestage3SARS-Cov-2epidemicsituation,itisnecessarytoputforwarda

methodofrapidresponseforanHASpositionstatementinordertoanswertotherequestsfromthe

French Ministry of Solidarity and Health, healthcare professionals and/or health system users’

associationsconcerningfollow-upofpregnantwomenduringtheCOVID-19outbreak.

Methods: A simpliﬁed 7-step process that favours HAS collaboration with experts (healthcare

professionals, healthsystemusers’associations,scientiﬁc societiesetc.),therestrictiveselection of

availableevidenceandtheuseofdigitalmeansofcommunication.Ashortandspeciﬁcdissemination

format,whichcanbequicklyupdatedinviewofthechangesinavailabledatahasbeenchosen.

Introduction

On14th March2020,France enteredstage3of theCOVID-19 epidemicoutbreak.Inaletterdated27thMarch2020,theFrench GeneralHealthDirectorate(DirectionGénéraledelaSanté-DGS) referredthemattertotheFrenchNationalAuthorityforHealth(Haute Autorité de Santé; HAS), with a view to drawing up general recommendationsdesignedtoensurecontinuityofcareforpregnant women during lockdown and travelrestrictions. Given the very limiteddataavailable,theFrenchHighCouncilforPublicHealth(Haut Conseil de SantéPublique HCSP)consideredpregnantwomeninthe third trimester of pregnancyto be atrisk of developing a severe form of COVID-19[1]. Theextensionoflockdownandtheroleandworkloadof healthcareprofessionals,leadtore-interviewingorganizationsforthe follow-upofpregnantwomenintermsofpreventionandcare.These rapidresponsesfocusonthefollow-upofpregnantwomenduring lockdownandmanagementofcasesofsuspectedand/orcon_ﬁrmed pregnantwomenwith COVID-19. They should be adapted according to the geographical particularities ofthe epidemic outbreak and access to localresources.Theserapidresponsesarebasedontheknowledge availableatthetimeofpublicationandaresubjecttochangeasnew informationbecomesavailable.

Methods

Inthecontextofthestage3SARS-Cov-2epidemicsituation,itis necessarytoputforwardamethodofrapidresponseforanHAS positionstatementinordertoanswertotherequests fromthe FrenchMinistryofSolidarityandHealth,healthcareprofessionals and/orhealthsystemusers_’associations.

Asimpliﬁed7-stepprocessthatfavoursHAScollaborationwith experts(healthcareprofessionals,healthsystemusers’associations,

scienti_ﬁcsocieties etc.),therestrictiveselection ofavailableevidence andtheuseofdigitalmeansofcommunication.Ashortandspeciﬁc dissemination format, whichcan bequicklyupdatedin view of changesinavailabledatahasbeenchosen.

Step 1) Selection of requests and identiﬁcation of issues requiringarapidresponsebythePresidentoftheHASCollege.

Step2)DataselectionandanalysisbytheHASteamsinclose collaborationwith experts named by the National Professional Councils (ConseilsNationaux Professionnels - CNP) and French scientiﬁcsocieties.Dataselectionwasrestrictedtothebestlevels ofevidenceandindescendingorder:

Frenchhealthagencies’recommendations

RecommendationsofFrenchandInternationalscientiﬁc socie-ties

WHOguidelines

Recommendations from international health agencies (NICE, INESS,etc.)

Literaturereviewsandrecent2019and2020scientiﬁcliterature withrapidcriticalanalysis

Step 3) Drafting of provisional rapid responses by a select working group: HAS team, previously appointed experts and patientassociations

Step4)Reviewandconsultation/informationofstakeholders. Thisstepincludesapanelofdesignatedhealthcareprofessionalsas well as representatives of the French institutions (Direction GénéraledelaSanté,Directiongénéraledel'offredesoins,HCSP). Thesereviewsarecarriedoutelectronicallyandallowaresponse withinashorttimeframe.

Step5)Finalizationof therapidresponsesbythepreviously appointedworkinggroup.

http://dx.doi.org/10.1016/j.jogoh.2020.101804

Available

online

at

ScienceDirect

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Step6)Validationanddisseminationoftherapidresponsesby theHAS. Thetextsarethenpublishedina shortformatonthe websiteoftheHAS,scientiﬁcsocietiesandassociationsinvolved. A warningis includedin thetext:"Theserecommendations, drawnuponthebasisoftheknowledgeavailableatthedateof theirpublication,aresubjecttochangeandarelikelytobeupdated inthelightofnewavailabledata”.

The experts' ties of interestare analysed by theHAS ethics ofﬁcerandthelegaldepartment,onthebasisoftheinformation available in the "DPI-HEALTH and TRANSPARENCY-HEALTH" databasesandareprovidedtothemembersof theHASCollege fortheirinformation

Step 7) Regular update of the rapid responses taking into account the developments in the scientiﬁc literature and the recommendationsfromthescientiﬁcsocieties.

ThisdocumentwasdrawnupjointlybytheHASandexperts appointedbytheCollègeNationaldes Gynécologueset Obstét-riciensFrançais(CNGOF),theCollègeNationaldesSages-femmes deFrance(CNSF),theCollègedelaMédecineGénérale(CMG),the SociétéFrançaisedeNéonatalogie(SFN),theSociétéfrançaisede pédiatrie(SFP),theFédérationFrançaisedesRéseauxdeSantéen Périnatalité (FFRSP), the Association Française de Pédiatrie Ambulatoire(AFPA). Therapidresponseswerereviewedbythe CollectifInterassociatifAutourdelaNaissance(CIANE).

Recommendations

Monitoringofpregnantwomenduringthepandemic

Withtheaimofreducingthehealthriskforpregnantwomen andrestricting theirmovements during lockdown,at thesame timeastheworkloadofhealthcare professionals,whilemaking pregnancymonitoringsafer,thereappearstobeaconsensusasto the need to take the following measures (to be adapted individually according to the clinical, psychological and social situationofeachwoman)(Table1).

Aninitialconsultation,(1stor2ndmonth)withamidwife,an obstetrician-gynaecologist,amedicalgynaecologistorageneral practitioner is recommended. Thisconsultation must include medicalfollow-up,informationonthepreventionofneuraltube closure anomalies (folic acid), prevention advice, support, answerstothewoman’sorcouple’squestions,andinformation. Remote consultation is possible: refer tothe COVID-19rapid responsesheet-“TeleconsultationandTelecare”bytheHAS[2] If the pregnancy is unwanted: refer to the COVID-19 rapid responsesheet“Voluntaryterminationofpregnancy”bytheHAS

[3]and theFrenchMinistryofSolidarityand Health’s recom-mendation[4].

Consultations by an obstetrician, medical gynaecologist, midwifeorgeneralpractitionermustincludemedicalfollow-up, preventionadvice,support,provideanswerstothewoman’s or couple’squestions,andinformation.

Allwomenshouldstillattendthethreeultrasoundconsultationsas partofpregnancyfollow-up

Ultrasoundshouldbecombinedwiththefollow-up consulta-tionasfaraspossible.Ifthisisnotpossible,theultrasoundandthe consultation will be carried out in two separate, face-to-face sessions,whileensuringthepatientdoesnothavetotraveltoa signiﬁcantextenttodoso.

Intheﬁrsttrimester,betweenweek11and14ofamenorrhea, andbasedontheresultsofthesecondpregnancyconsultation inthethirdmonth(physicalexamination,screening, declara-tionofpregnancy,presumeddateofdelivery),this consulta-tionmustbeusedtoestablishthetypeof careaccordingto the level of risk, and to determine whether the patient should be referred for either hospital or ambulatory care follow-up.

Inthesecondtrimester,betweenweek20and25ofamenorrhea, basedontheresultsofthe5thmonthconsultation

Inthethirdtrimester,betweenweek30and35ofamenorrhea, basedontheresultsofthe7thmonth/8thmonthconsultation.

In the case of multiple and high-risk pregnancies it is recommendedtokeepthemonthlyortwice-monthlyultrasound monitoring at most and to adapt monitoring according to the clinicalsituationandtheprogressionoftheepidemic.

The availability of ultrasound scans in ambulatory care is impactedbytheCOVID-19epidemic(asurveyconductedbythe FrenchCollegeofFetalUltrasoundrevealsthatbetween10and15 % of practices are believed to be closed) [5]. It thus appears essential that all stakeholders, doctors (obstetricians, medical gynaecologists,radiologists,generalpractitionerstrainedinfoetal ultrasound) and midwives in ambulatory care maintain their consultationappointmentsfor screeningultrasounds.The Inter-national Society of Ultrasound in Obstetrics and Gynaecology (ISUOG)offersthreeoptionsforperformingultrasound examina-tionsoutsideofroutineexaminations,dependingontheurgencyof theclinicalsituation: "tobedonewithout delay";"to besafely deferred";"todelayduringlockdown"[6].

Table1

Follow-upforpregnantwomenduringtheCOVID-19pandemic:recommendations.

RapidResponse#1:Pregnantwomeninthe3rdtrimesterofpregnancyareconsideredtobeatsigniﬁcantriskofdevelopingasevereformofCOVID-19.Lockdownand barriermeasuresmustbefollowedandreinforced.

RapidResponse#2:Complywithlockdownmeasuresforallpregnantwomen.

RapidResponse#3:Structurethefollow-upofpregnanciesaroundthethreeobstetricalultrasounds. RapidResponse#4:Follow-uponwomenwithlowobstetricriskinambulatorycareasfaraspossible.

RapidResponse#5:Awoman'spsychologicalandemotionalstateshouldbecloselymonitoredbyhealthcareprofessionalsduringallfollow-upconsultations,early prenatalassessmentsandallprenatalclasses.

RapidResponse#6:Offerpsychologicalsupport,preferablyremotely,iftheneedisidentiﬁedbythehealthcareprofessionalorifitisrequestedbythepatient. RapidResponse#7:Offerfollow-upbyremoteconsultationorface-to-facedependingontheobstetricriskandthedevelopmentoftheclinicalsituation,butalso

dependingonthewoman’ssocialandpsychologicalsituationandthedomesticviolencerisk.

RapidResponse#8:Adaptmonitoringofhigh-riskpregnancies,whileensuringclosermonitoringofassociatedco-morbiditiesandtheriskofsevereformsofCOVID-19. RapidResponse#9:Ensurecloserfollow-upofpregnanciessuspectedordiagnosedCOVID-19,withprioritytoremoteconsultation.

RapidResponse#10:Maintainprenatalclassesbyremoteconsultationorbycombiningthemwithotherconsultationslastingasufﬁcientamountoftimeandprepare womenforbirthandearlydischargefromthematernityunit.

RapidResponse#11:Modulatetheorganizationoffollow-upofpregnantwomenaccordingtothegeographicalparticularitiesoftheepidemicandaccesstolocal resources.

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Promoteintermediateconsultations(4thand6thmonth)byremote consultation

Forwomenatlowobstetricalrisk:byremoteconsultation. For women athighobstetrical orpsycho-socialrisk:evaluate

beforehand,bytelephonecontact,therelevanceofmaintaining the4thand6thmonthface-to-faceconsultations.

Thirdtrimesterconsultationorganization

Consolidatethe7th(withultrasound)and8thmonthvisits(by scheduling them attheend ofmonth 7/startof month 8)or maintainbothvisitsbased ontheobstetricalriskassessment. Theyaretobecarriedoutface-to-face,atthepracticeoratthe hospital.

Conductthe9thmonthconsultationinperson.

Carryouttheanaesthesiaconsultationbytelephoneandsenda questionnairebye-mailﬁrst.

TheAmericanCollegeofObstetriciansandGynecologists(ACOG) recommendsreducingthenumberofconsultationstothenecessary minimum (without specifying) and adapting the follow-up of pregnant women individually by relying on the local care community(generalpractitioners,midwives)[7].TheRoyalCollege ofObstetriciansandGynaecologists(RCOG)recommendspromoting remoteconsultationsto ensure social distancingandorganizing face-to-faceconsultationsbasedon pregnancy screening,tomonitor risks during pregnancy [8]. A review of the literature also recommendsminimal follow-upofpregnant womenatlow obstetric riskduringtheepidemicperiod,byspacingoutvisits,andremote consultationforvisitsat6and7/8months[9].Additionalremote consultationsarealsorecommendedforwomenatrisk(highblood pressure,diabetes,depression).

Follow-upofwomenatlowobstetricalriskshouldbecarriedoutin ambulatorycareasfaraspossible

Depending on access to local resources and throughout pregnancy follow-up, pregnant women can go to a healthcare professional,tothetestcentre,totheradiology centreforprocedures requiredduringfollow-up,bycontactingthembeforehandandby appointmentonly.Forvisitstotheofﬁcesofmidwives,obstetricians, medical gynaecologists, and general practitioners, it is recom-mendedthatwomenweara maskonly iftheyhaverespiratory symptoms[1].Wearingsurgicalmasksinwaitingroomsshouldbe recommended,iftheconsultation is ina hospitalenvironment [1,10]. Follow-upofwomeninprecarioussituationsorinsituationsof psychologicalorsocialvulnerability

Face-to-faceconsultationsarepreferable.Itisadvisablethata pregnancyconsultantaccompanies them toidentifya need for furtherfollow-uporreferraltotheappropriatechannels.

Follow-upofwomenatriskofobstetricalcomplicationsshouldbe adaptedtotheprogressionofthepregnancy

Depending on whether the risk is refuted or conﬁrmed, whetherthe prognosisis favourable or not, this follow-upcan becarriedoutbyamidwifedependingonthelevelofrisk[11].If hospitalization at home is indicated, it should be preferred dependingontheresourcesavailablelocally[12].

Follow-upbythemidwifeistobeencouragedasfaraspossible at home(while ensuring hygienerules arefollowed) or at the

practiceifitiseasyforthepregnantwomantovisit(ifshehasacar, toavoidtakingpublictransport).

Recommend medical leave for pregnant patientsin the3rd trimester:Aspartofthepreventionmeasuresaimedatlimitingthe spread of the coronavirus, these patientscan beneﬁt from the waiver allowing peopleat risk of developinga seriousform of infectiontobeneﬁtfrompreventivematernityleave.

Psycho-socialsupportforpregnantwomen

Duringlockdown,itisadvisabletomaintainearlyprenatalcare, preferablyby remote consultation,in order toidentifysigns of stress,anxiety,vulnerability,sleepdisorders,depressiveepisodes, addictions,andanyformofinsecurityearlyon,andtoreferwomen whorequestitforpsychologicalsupport,evenremotely,ortoa suitablesolutionintheeventofriskofdomesticviolence[13].

Birth and prenatal classes can be carried out by remote consultationbymidwives,individually,prioritizingthe participa-tionofcouplesinthe3rdtrimesterofpregnancy.Thiswillhelp reinforcethemother’sorcouple’sself-conﬁdenceinviewofthe birth,thereturnhomeandcareofthenewborn,andaccompany themintheirparentingpractices.Psychologicalsupportmustbe maintainedifnecessary.

Itisessentialtoprepareforchildbirthandtherecommended earlydischargefromthematernitywardat48hoflifeduringthe COVID-19pandemic[14].Skin-to-skincontactandbreastfeeding arepermittedaccordingtothecurrentstateofknowledge.Support mustbeprovidedforinitiationofbreastfeedingandmother-child bondinginthedeliveryroomandduringthepost-natalperiod.

Admissionforchildbirth,deliveryandpost-natalcare

Itisimportanttorecalltheneedforaccuratequestioningabout possible signs of COVID-19infection on admission of pregnant women(andtheirpartner)[15].

Screeningofpregnantwomenonadmission

According toa recent publication,theprevalence of women diagnosed with COVID-19in a cohort of 215 women in labour admittedtotwoNewYorkmaternityhospitalswas13.8%(29/215). In light of thisstudy, it would berelevanttorecommend, ina comparableepidemiccontext,systematicscreeningofwomenon admission. This would make it possible to refer mothers to a COVID-19 sectorand toprotectthe healthcare teams(personal protectiveequipment)andnewborns[16].

Whilethedelaysinobtainingtheresultsofcurrenttestswillnot haveanimpactonthemanagementofchildbirth,apositiveresult for themother would howeverhavea collective impact(social distancing and isolation of the mother and child, reduced circulationof theviruswithinthehospitalandafterdischarge). Thispotentialimpactiscomparabletothatwhenscreeningany patient seeking care in a structure where there is a risk of contamination(stay,highriskprocedure)andraisesthequestion of ethics in this type of situation. The HAS recalls the WHO recommendation to increase testing. The particular case of pregnant women arriving at or hospitalised in the maternity hospital or the obstetrical emergency unit in labour will be clariﬁedaccording tothe HAS’srecommendationonthe useof tests,whichcanbeadaptedtothelocalepidemiccontext. Supportfrompartners/familymembers

Homogeneityofpracticesisdesirableonthispointinorderto avoid women having totravelany distance.Professionals must informwomen,fortheirsafetyandthatoftheirchild,thatitisnot recommendedtochangehealthfacilityatthelastminute.

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The woman’s partneris allowed in the delivery room under certainconditions[17,18].

Novisitsareallowedafterthebirth[17,18].

AccordingtotherecommendationsoftheRCOG,the accompa-nyingpersonmayassistatthebirthifhe/sheisasymptomatic[8].The placeoftheaccompanyingpersoninpost-natalcareislefttothe teams’discretion,dependingontheequipmentavailableandwithan emphasisontheprotectionofmothers,newbornsandstaff.

The HAS considers that the asymptomatic accompanying personcanremainintheroomprovidedthattheycomply with the strict rules set out by the establishment and that the establishmenthastheappropriatepersonalprotectiveequipment andstafftoensurethattheserulesareappliedwithoutaffecting thesmoothrunningofthematernityward.

Adaptingteamworkduringtheepidemicperiod

Teamwork,communication andinformation sharingmustbe strengthenedbyinpatientandoutpatientcoordination between theambulatoryand hospitalcare.Ambulatorycareisdeﬁnedas medical care carried out byany health non-hospital personnel (midwife,generalpractitionerandgynaecologist-obstetricianwho workin the city). The methods are determined jointly by the healthcareprofessionalsinvolvedincaringforwomen(midwives, obstetricians, medical gynaecologists, paediatricians, general practitioners).Theyareessentialinparticularforthereferralof high-riskpregnancies,womeninprecarioussituationsorwomen insituationsofsocialorpsychologicalvulnerability.

Supportforambulatorycarecare

Itappearsthatsomeofthedaycarestructures(inFrance)are closed. These structureshave an important role to play in the continuityofcareandmustparticipateinthefollow-upoflow-risk women by restricting their activities, while following barrier measures.

Giventheroleofambulatorycaremidwivesinthefollow-upof pregnant women, it is essential to reinforce the means of protection allocated to them (masks, overalls, gloves, hand sanitizeretc.).

Institutionsmustdrawupalistofambulatorycaremidwives whocanprovidefollow-upcareforpregnantwomentoreinforce in and outpatient coordination between the ambulatory and hospitalcare.The roleof perinatalnetworksis essential inthe epidemicoutbreakcontext.

All of these measures aim to step up outpatient care and facilitatethemanagementofpatientswithCOVID-19byobstetrical teamsinhealthfacilities.

Organisation of follow-up of pregnant women should be modulated according to the geographical particularities of the epidemicoutbreakandaccesstolocalresources.

Casesofpregnantwomensuspectedtohaveand/orconﬁrmedtohave COVID-19

PregnantwomanwithsignssuggestingCOVID-19:fever,cough, respiratorysigns(dyspnoea),orsignsofpneumonia

Ifinfectionissuspected,thepatientshouldconsulttoruleout any other illnesses (fever). Her state of severity should be assessed,andanyobstetriccomplicationsidentiﬁedwherethere are any. She should consult her general practitioner; in accordancewiththehygienemeasuresinplaceand a COVID-19diagnostictestmust beoffered.Thisconsultation mustbe carriedoutwhileensuringbarriermeasuresarefollowedasfar

aspossible(thepatientshouldwaitaloneinthewaitingroom, andwearamask).

Thepatientcanalsophonetheemergencyservicesorgotothe obstetricemergencyunitinthehospitalorclinicinwhichsheis beingmonitored, ensuringshecalls themﬁrst(special phone line)andinformstheteamonarrivaloftheriskofinfectionso thatshecanbeprovidedwithamaskandbeisolated.

Ifascreeningultrasoundwasscheduledwithintwoweeksfora woman with suspected or conﬁrmed COVID-19, it may be rescheduledatalaterdate,oncethepatienthasrecovered,within theultrasounddeadline.

According to the opinion of 8th April 2020, any woman suspectedorconﬁrmedtohavethevirusmustbemanagedbythe generalpractitionerandthereferringobstetricalteam.Anywoman with signs of severity or aggravating comorbidities should be managedinthehospitalsetting[19–22].

Obstetricalemergencymanagement

The CNGOF guidelines describe management in obstetric emergencies [17,18]. In particular, theyspecify the criteria for hospital or intensive care admission and knowncomorbidities (women in third trimester of pregnancy, overweight women, women with pregnancy-related hypertension, pre-eclampsia, gestational or pre-existing diabetes, chronic respiratory failure, historyofheartdiseaseortransplant).

Hospitalizationshouldbediscussedforpregnantwomenwith co-morbidities even in the absence of initial clinical signs of severity,particularlyduringthethirdtrimester.

Intheabsenceofreasonsforhospitalization,itisrecommended to test (RT-PCR on nasopharyngeal swab) all suspect pregnant women:

Withpendingresult: toautomaticallybe consideredpositive. Return home is possible while waiting for the results with respecttoisolationmeasures.

Negative test: given the sensitivity of the test, it cannot be completelyruledoutthatwomenarenotcontagious(relative sensitivityofRT-PCR).Itisrecommendedtokeepthemaskonto avoid transmitting any infectious agent responsible for the symptoms.Disappearanceofsymptomsshouldbeconﬁrmedby anoutpatientmonitoringprocedureaccordingtolocal organi-zation.

Positivetest:itisrecommendedtokeepthemaskonoutsideand inallcircumstances,outpatientmonitoringprocedureaccording tolocalorganization.

Hospitalizationmanagementprotocol

The CNGOF recommendations describe the management protocolintheeventofhospitalization[17].

Managementofapatientreturninghomefromanemergencyroom visitorhospitalization

Contactevery48h(traceresultstoberecoveredandcallsmade) bytheobstetricalemergencyteam.

MinimizetheriskofCOVID-19transmissionwithhomeisolation for 14 days for the woman and her partner (to whom self-monitoringinstructionsandhygieneprecautionstobefollowed shouldhavebeengivenandexplained).

Giveprioritytoremoteconsultationwheneverpossible. Consultationwithadoctorthreeweeksafterdischarge.

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Follow-upofpregnantwomenafterrecovery

Duetothelackofknowledgeastotheconsequencesofthedisease, clinicalandultrasoundmonitoringofpregnantwomenandtheir unbornchildbyanobstetricianisrecommended.Thisisnecessary toassessfoetalgrowthandthevolumeofamnioticﬂuid. Management is similartothat forhigh-risk pregnancieswith

medical follow-up by the referring doctor and continuity of follow-upbyamidwifeathomeoramidwifeinhospital. Theneedforadditionalultrasoundscansshouldbediscussedon

acase-by-casebasisdependingontheseverityofthemother’s symptoms(noknownteratogenicriskandnoimpactontermor methodofdelivery).

Speciﬁcprenataldiagnosismanagementofinfectedpatientsis not required except in rare cases of severe hypoxia requiring mechanicalventilation, which mayresultinfoetalhypoxia and abnormal brain development (diagnostic ultrasound+MRI rec-ommended).Incaseofseverepneumoniawithoutseverehypoxia, additionalultrasoundtocontrolfoetalgrowthshouldbediscussed. Recommendationa

RapidResponse#1:Pregnantwomeninthe3rdtrimesterof pregnancyareconsideredtobeatsigniﬁcantriskofdevelopinga severeformofCOVID-19.Lockdownandbarriermeasuresmustbe followedandreinforced.

RapidResponse#2:Comply withlockdown measuresforall pregnantwomen.

Rapid Response #3: Structure the follow-up of pregnancies aroundthethreeobstetricalultrasounds.

RapidResponse#4:Follow-uponwomenwithlowobstetric riskinambulatorycareasfaraspossible.

RapidResponse#5:A woman'spsychological andemotional state should be closely monitored by healthcare professionals duringallfollow-upconsultations,earlyprenatalassessmentsand prenatalclasses.

Rapid Response #6: Offer psychological support, preferably remotely,iftheneedisidenti_ﬁedbythehealthcareprofessionalor ifitisrequestedbythepatient.

RapidResponse#7:Offerfollow-upbyremoteconsultationor face-to-facedependingontheobstetricriskandthedevelopment oftheclinicalsituation,butalsodependingonthewoman’ssocial andpsychologicalsituationandthedomesticviolencerisk.

RapidResponse#8:Adaptmonitoringofhigh-riskpregnancies, whileensuringclosermonitoringofassociatedco-morbiditiesand theriskofsevereformsofCOVID-19.

Rapid Response#9: Ensure closer follow-up of pregnancies suspected or diagnosed COVID-19, giving priority to remote consultation.

Rapid Response #10: Maintain prenatal classes by remote consultation or by combining them with other consultations lastingasufﬁcientamountoftimeandpreparewomenforbirth andearlydischargefromthematernityunit.

RapidResponse#11:Modulatetheorganizationoffollow-upof pregnantwomenaccordingtothegeographicalparticularitiesof theepidemicandaccesstolocalresources.

DeclarationofCompetingInterest

Theauthorsdeclarenocompetinginterests

Acknowledgements

WewouldliketoextendourthankstoMrsMadeleineAkrich, France Artzner, Anne Evrard from the Collectif Interassociatif AutourdelaNaissance(CIANE)whoreadtherecommendations.

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systematic review of 108 pregnancies. Acta Obstetr Gynecol Scand 2020,doi:http:// dx.doi.org/10.1111/aogs.13867[Internet].[cited2020Apr12].Availablefrom:. [21]CAPWHN.COVID19-Suggestions for thecare of the perinatal population [Internet]. Availablefrom:.2020.https://capwhn.ca/wp-content/uploads/ 2020/03/CAPWHN_COVID-19_Mar-25-2020.pdf.

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[22]CentersforDiseaseControlandPrevention.Pregnancyandbreastfeeding. Informationaboutcoronavirusdisease. [Internet].2020.Availablefrom:. 2019.https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/ pregnancy-breastfeeding.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Fcoronavirus%2F2019-ncov%2Fprepare%2Fpregnancy-breastfeeding. html. AlexandreJ.Vivantia,_* PhilippeDeruelleb,i OlivierPiconeb,j SophieGuillaumec Jean-ChristopheRozed BlandineMuline FabienneKochertf IsabelleDeBecog SophieMahutg AdrienGantoisc ChloéBarasinskic,k KarinePetitprezh Anne-FrançoisePauchet-Traversath AlcyoneDroyh AlexandraBenachia,b a_Service_de_Gynécologie_{Obstétrique,}_Hôpital_Antoine_Béclère,_AP-HP,

UniversitéParis-Saclay,92140Clamart,France

b_Collège_National_des_{Gynécologues}_{Obstétriciens}_Français,₇₅₀₀₂

Paris,France

c_Collège_National_des_Sages-Femmes_de_France,₇₅₀₁₅_Paris,_France d

ConseilNationaldesProfessionnelsdePédiatrie,75015Paris,France

e_French_Federation_of_Perinatal_Health_Networks,₃₁₀₀₀_Toulouse,

France

f_French_Association_of_Ambulatory_Paediatrics,₃₃₄₀₀_Talence,_France g_College_of_General_Medicine,₇₅₀₁₇_Paris_8,_France h_Guidelines_Department,_French_National_Authority_for_Health,₉₃₂₀₀

Saint-Denis,France

i_Service_de_Gynécologie_{Obstétrique,}_Hôpital_de_Hautepierre,_Faculté

deMédecinedeStrasbourg,67000Strasbourg,France

j

DivisionofObstetricsandGynecology,“LouisMourier”Hospital, ParisUniversity,IAMEINSERMU1137,APHP(Paris,France)GRIG (GroupedeRecherchesurlesInfectionspendantlaGrossesse),92700 Colombes

k_Université_Clermont_Auvergne,_CNRS,_CHU_{Clermont-Ferrand,}

SIGMA,INSTITUTPASCAL,F63000ClermontFerrand,France * Correspondingauthor. E-mailaddress:alexandre.vivanti@aphp.fr(A.Vivanti).