key: cord-0747410-nuona62o
authors: Romagano, Matthew P.; Guerrero, Kerly; Spillane, Nicole; Kayaalp, Emre; Smilen, Scott W.; Alvarez, Manuel; Alvarez-Perez, Jesus; Francis Kim, Antonia; Aschner, Judy; Al-Khan, Abdulla
title: Perinatal outcomes in critically ill pregnant women with coronavirus disease 2019
date: 2020-06-03
journal: Am J Obstet Gynecol MFM
DOI: 10.1016/j.ajogmf.2020.100151
sha: c2df35a38a22aa71337970f6c19b3b95a0d4b689
doc_id: 747410
cord_uid: nuona62o

nan

Perinatal outcomes in critically ill pregnant women with coronavirus disease 2019

Early reports suggested that pregnant women were not at an increased risk for severe disease or death from coronavirus disease 2019 (COVID-19). 1 However, few publications have described critical illness in pregnant patients with COVID-19. This study describes the clinical characteristics and outcomes of critically ill mothers and their neonates within our health network since the onset of the COVID-19 pandemic in New Jersey.

This institutional review boardeapproved, retrospective case series describes all pregnant women and their neonates requiring critical care for severe COVID-19 within our network's 2 largest hospitals in March 2020 and April 2020. Maternal demographic information, delivery method and indication, clinical symptomatology, imaging and laboratory findings, and treatment data were collected. Neonatal outcomes were also collected, including real-time polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

There were 1053 deliveries between both hospitals during the study period, with 73 (6.9%) documented symptomatic pregnant patients with COVID-19. Of the 73 patients, 31 (42%) were admitted for management of COVID-19 symptoms. Among the 31 patients, 8 (26%) required intensive care unit (ICU) admission, 6 (19%) required intubation, and 1 (3.2%) was supported with extracorporeal membrane oxygenation (ECMO). Therefore, 8 of 73 (11%) patients who exhibited COVID-19 symptoms developed critical illness. Table 1 describes the maternal demographics, clinical characteristics, and treatments of the 8 critically ill patients treated during the study period. Mean age and body mass index were 30.5AE9.0 years and 34AE7.9 kg/m 2 , respectively. Median gravidity and parity were 2.5 (3.5) and 1 (2.75). Mean gestational age at presentation was 30.6 weeks, and mean gestational age at delivery was 31.4 weeks. Of note, 7 (87.5%) of the women were Hispanic, despite the 2 health centers having Hispanic populations of 24.7% and 8%, respectively. Two women had preexisting conditions (chronic hypertension, asthma), and 1 presented with hemolysis, elevated liver enzyme, and low platelet (HELLP) syndrome. Among the 8 critically ill patients, 7 (87.5%) delivered preterm by primary cesarean delivery, and 1 is yet to deliver.

Furthermore, among the 8 critically ill patients, 5 had an oxygen saturation less than 94% on admission. Only 1 was febrile on admission, although 5 (62.5%) developed fever during hospitalization. Most had cough (75%) and dyspnea (87.5%). All had elevated transaminases and D-dimer levels. Moreover, C-reactive protein (CRP), lactate dehydrogenase, and interleukin-6 levels were elevated in all women who received these tests.

Treatments are summarized in the Supplemental Figure. All required oxygen supplementation; most received a combination of medical interventions. Of the 8 critically ill patients, 6 (75%) required intubation, and 1 (12.5%) received venovenous ECMO for 12 days. Three women required norepinephrine and prone positioning, which was accomplished after delivery. All women were discharged in stable condition.

Patients 1 through 8 in Table 1 are paired with neonates 1 through 8 in Table 2 (patient 5 is yet to deliver). All neonates were premature and required neonatal ICU admission. Respiratory distress (85.7%) was universal and predominantly severe. Neonatal morbidities were significant. All neonates tested negative by RT-PCR for SARS-CoV-2.

Our case series illustrates the potential severity of COVID-19 in pregnant women and provides a model of management that may be useful for obstetrical providers. Most women in our series were Hispanic, which is disproportionately high given the demographics of our institutions. Information on other social determinants of health was not available. This finding warrants further investigation considering emerging racial disparities of COVID-19erelated deaths. 2 Most women had rapid onset of disease, developed severe hypoxia, and had significant findings on lung imaging. Fever on initial presentation was uncommon. All had elevation of liver transaminases, CRP, and D-dimer.

There are conflicting data on the risk for preterm delivery associated with COVID-19 in pregnancy. 3, 4 In this study, 7 of 8 women with critical respiratory illness required preterm delivery with the goal of reducing respiratory compromise by decreasing oxygen requirements and enhancing diaphragmatic excursion. 5,6 Antenatal corticosteroids were not given universally because of the theoretical potential to exacerbate COVID-19 and pulmonary edema. Rapid deterioration was another limiting factor.

All women were discharged home in good health following multimodal and multidisciplinary approaches including intubation, prompt delivery, off-label use of experimental therapies (eg, remdesivir, convalescent plasma), and ECMO. Although there was a significant burden of prematurity, each neonate improved as expected with neonatal intensive care, and there was no evidence of vertical transmission.

Obstetrical providers should be aware of the potential for COVID-19 to progress to critical illness in pregnancy. Without clear guidelines for treatment, providers are left with unproven therapies without sufficient safety data, and although treatment was ultimately successful in all patients, it

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Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia

Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records

Human metapneumovirus infection and acute respiratory distress syndrome during pregnancy

Does delivery improve maternal condition in the respiratory-compromised gravida?

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is impossible to state whether any individual intervention is an improvement over standard supportive care. As research evolves during this crisis, management options will be clarified. Providers should recognize clinical deterioration in pregnant women and intervene swiftly to limit maternal and fetal harm. This paper is part of a supplement that represents a collection of COVIDrelated articles selected for publication by the editors of AJOG MFM without additional financial support.The authors report no conflict of interest.