key: cord-0862905-l6y3n21b authors: Vega, Marisa; Hughes, Francine; Bernstein, Peter S.; Goffman, Dena; Sheen, Jean-Ju; Aubey, Janice J.; Zork, Noelia; Nathan, Lisa title: From the Trenches: Inpatient Management of COVID-19 in Pregnancy date: 2020-06-15 journal: Am J Obstet Gynecol MFM DOI: 10.1016/j.ajogmf.2020.100154 sha: 538985fd11642c45e01f3d82604e00a7558cb606 doc_id: 862905 cord_uid: l6y3n21b ABSTRACT The novel coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 has become a pandemic. It has quickly swept across the globe leaving many clinicians to care for infected patients with limited information about the disease and best practices for care. Our goal is to share our experiences of caring for pregnant and postpartum women with novel coronavirus disease 2019 (COVID-19) in New York, the COVID-19 epicenter in the United States and review current guidelines. We offer a guide, focusing on inpatient management, including testing policies, admission criteria, medical management, care for the decompensating patient, as well as practical tips for inpatient antepartum service management. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread dramatically 22 around the world, but there has been little evidence-based data to guide clinical management 23 of patients with coronavirus disease 2019 , and even less on the management of 24 obstetric patients. It is known that the spectrum of disease attributed to COVID-19 is wide 25 including asymptomatic infection, mild upper respiratory disease, pneumonia, severe 26 respiratory distress, and death. 1 Common presenting symptoms include fever, dry cough, 27 dyspnea, chest pain/tightness, fatigue, and myalgias. Less commonly, pregnant women may 28 report headache, confusion, rhinorrhea, sore throat, hemoptysis, vomiting, and diarrhea. 1 29 Anosmia or ageusia with COVID-19 has also been reported. The incubation period from 30 exposure to symptom onset is 4-5 days, with a range of 2-14 days. 1,2 31 Initial data suggests that pregnant women are not more susceptible to SARS-CoV-2 infection 32 than nonpregnant patients. Physiologic and anatomic changes associated with pregnancy, 33 however, may predispose patients to an increased risk for respiratory failure. 3 Patients with co-34 morbidities, such as asthma or other chronic lung disease, cardiovascular disease, hypertension, 35 HIV or other immunocompromised patients, body mass index >40, pre-gestational diabetes, 36 chronic kidney disease, and liver disease may have more significant adverse outcomes, First-line testing is performed using SARS-CoV-2 RT PCR with a nasopharyngeal swab. The test 57 has a high specificity and moderate sensitivity (60-80%) 4 . Swabbing of the nasopharynx is the 58 preferred choice for swab-based testing due to increased detection rates. 1 59 60 The CDC currently recommends that clinicians use their judgment to determine whether a 61 patient should be tested. 1 All patients admitted to the hospital should have basic labs and imaging performed during their 107 initial evaluation (Table 3) . Upon admission, confirm contact and droplet isolation precautions 108 have been transferred to the patient's in-patient room (Table 4 ). For patients with hypoxia 109 (SpO2 <95%), check D-dimer, procalcitonin, ferritin, lactate dehydrogenase (LDH), and troponin 110 levels ( Table 5 ). If the clinical presentation is concerning for bacterial superinfection, consider 111 obtaining a sputum culture and/or blood culture. Monitor fluid status, with hourly evaluation of 112 intake and output, and avoid volume overload. Conduct multidisciplinary discussions with 113 representation from obstetrics, anesthesiology, pediatrics, and nursing to plan for the next 114 steps in patient management. Practical tips for antepartum service management can be found 115 in Table 6 . but has been noted to be increased in COVID-19 patients, particularly among those requiring 129 admission to the ICU. 1 It is important to note that markers of inflammation like CRP can be 130 mildly elevated during normal pregnancy (Table 7) . 5 Anecdotally, we have noted that CRP levels 131 >10mg/L have correlated with more significant disease and tends to increase/decrease with 132 worsening/improvement of the disease course. However, there are currently no reference 133 levels related to CRP and COVID-19 infection in pregnancy in the literature. (Table 7 ). In non-pregnant women, D-dimer ranges from 0.22-0.74 mcg/mL while in 249 the third trimester, levels range from 0.13-1.7 mcg/mL. 24 The threshold for the level of D-dimer 250 that should raise concern in pregnancy is not known, but consideration of prophylactic or 251 therapeutic anticoagulation based on the given clinical circumstances is critical, if no 252 contraindication exists (e.g. active bleeding or severe thrombocytopenia). This may be most 253 relevant for symptomatic patients, particularly those with thrombocytopenia and/or an 254 abnormal coagulation profile. It should be noted that abnormal PT or PTT is not a 255 contraindication to anticoagulation, and the full clinical picture should be taken into account. -One person outside of the patient room is stationed at a computer to check lab results, write notes, and enter orders while on speaker phone with the team in the room -The provider stationed at a computer keeps the team in the room informed of pertinent details as handoff sheets and other reference materials cannot be easily or safely accessed when in full PPE in the patient's room • Obtain ambulatory pulse oximetry measurements (walk test) for stable patients as part of the physical exam -patients may appear deceptively well without exertion • Pocket ultrasounds for biophysical profiles may be useful for COVID-19 patients as an alternative to nonstress tests to limit the number of providers entering the room Step 1: Ask each patient and visitor the following questions. "Yes" to any question = POSITIVE screen Have you been diagnosed with COVID-19? Have you been exposed to someone with known or suspected COVID-19 in the last 14 days? Have you recently had, or do you currently have any one of the following? Step 2: Measure temperature. A temperature ≥ 100.0°F = POSITIVE screen Take the temperature of all patients who present to the hospital at entry if possible and/or at presentation to triage or labor and delivery units, as well as their support person *If your institution has the resources, consider sending a test for SARS-CoV-2 infection on all patients who present to the triage or labor and delivery units for Disease Control and Prevention Accessed 4/30/20 Coronavirus Disease 2019 (COVID-451 19) and Pregnancy: What obstetricians need to know Respiratory Failure and 454 Mechanical Ventilation in the Pregnant Patient Laboratory diagnosis of emerging human coronavirus infections -the 456 state of the art Screening all pregnant 458 women admitted to Labor and Delivery for the virus responsible for COVID-19 Coronavirus disease 2019 infection among 461 asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an 462 affiliated pair of New York City hospitals 8. The Society for Maternal-Fetal Medicine Clinical predictors of mortality due to COVID-19 based 472 on an analysis of data of 150 patients from Wuhan, China Clinical Characteristics of Coronavirus Disease 2019 in China Procalcitonin in patients with severe coronavirus disease 2019 (COVID-19): A 477 meta-analysis The American College of Radiology. ACR Recommendations for the use of Chest Radiography 479 and Computed Tomography (CT) for Suspected COVID-19 Infection for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection Accessed 5/13/20 In Vitro Antiviral Activity and Projection of Optimized Dosing Design 484 of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 485 (SARS-CoV-2) Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in 487 inhibiting SARS-CoV-2 infection in vitro Hydroxychloroquine and azithromycin as a treatment of 489 COVID-19: results of an open-label non-randomized clinical trial Evidence of transplacental passage of 492 hydroxychloroquine in humans Ocular toxicity in children exposed in utero to antimalarial 494 drugs: review of the literature Hydroxychloroquine Use and Hemolytic Anemia in G6PDH-Deficient Patients Infectious Diseases Society of America. Infectious Diseases Society of America Guidelines on the 503 Treatment and Management of Patients with COVID-19 American College of Obstetricians and Gynecologists Anticoagulant treatment is associated with decreased 510 mortality in severe coronavirus disease 2019 patients with coagulopathy ISTH interim guidance on 513 recognition and management of coagulopathy in COVID-19 The Society for Maternal-Fetal Medicine. Coronavirus (COVID-19) and Pregnancy: What 518 Maternal-Fetal Medicine Subspecialists Need to Know Labor and Delivery 523 Guidance for COVID-19 COVID-19 in Children, Pregnancy and Neonates: A Review of 526 Epidemiologic and Clinical Features Maternal and Perinatal Outcomes with COVID-19: a systematic review 528 of 108 pregnancies Acute respiratory failure in pregnancy Management of Acute Respiratory Failure in Pregnancy. Semin Respir Crit Care 532 Med NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary Society for Maternal-Fetal Medicine and Society for Obstetric and Anesthesia and Perinatology. 539 Labor and Delivery COVID-19 Considerations