Care of critically ill pregnant patients with coronavirus disease 2019: a case series

The novel coronavirus disease 2019 (COVID-19), the outbreak of which has caused a global pandemic, is spreading rapidly throughout the United States, with major metropolitan areas such as Philadelphia, seeing a dramatic rise in infection rates. Although pregnant women are not affected more severely than nonpregnant patients,1Breslin N. BC Baptiste C. Gyamfi-Bannerman C. et al.COVID-19 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals.Am J Obstet Gynecol MFM. 2020; ([Epub ahead of print])Google Scholar a number of obstetrical patients will nevertheless require intensive care similar to their nonpregnant counterparts. Here, we review 5 critical cases of COVID-192Wu Z. McGoogan J.M. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention.JAMA. 2020; ([Epub ahead of print])Crossref Scopus (11977) Google Scholar during pregnancy, as well as general management principles. This was a retrospective, multicenter case series of symptomatic pregnant women who had a positive result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and required critical care. The clinical courses of 5 pregnant women with severe cases of COVID-19 disease, all requiring mechanical ventilation, are described below and summarized in the Table. Testing for the presence of SARS-CoV-2 was done through a reverse transcription polymerase chain reaction test of a nasopharyngeal swab unless otherwise specified.TableMaternal and clinical characteristics of critically ill pregnant patients with COVID-19CharacteristicsCase 1Case 2Case 3Case 4Case 5Age (y)2933392735Race/ethnicityAsianWhiteHispanicBlackWhiteBMI (kg/m2)24.627.842.534.732Admission GA31 wk 2 d26 wk 0 d28 wk 3 d30 wk 3 d25 wk 2 dChief complaintFever, dyspneaFever, cough, dyspneaFever, coughFever, cough, dyspneaFatigue, cough, rhinorrhea, headache, fever, dyspneaMedical comorbiditiesChronic kidney disease (C1q nephropathy), hypertension (on ACE inhibitor before pregnancy)Mild, intermittent asthmaObesity, hypertension, insulin-dependent diabetesHypertension (no medication)obesityNotable admission laboratory resultsElevated creatinine (patient baseline)NoneElevated CRP and lactic acidThrombocytopeniaElevated amniotransferasesNumber of days from symptom onset to intubation9101479Adjunctive therapyHCQ, remdesivirHCQ, remdesivirHCQ, remdesivirHCQ remdesivirHCQ, remdesivirAntenatal steroids and HD administeredBetamethasone, HD 3Dexamethasone, HD 3, 4Betamethasone, HD 7, 8Betamethasone, HD 3, 4Betamethasone, HD 1, 2Additional clinical detailsIntubated at 31 wk 4 d, extubation HD 16 with reintubation, final extubation HD 20, discharged HD 24Intubated at 26 wk 1 d, prone ventilation (× 2), tracheostomy 29 wk 1 d, suspected inferior vena cava thrombusIntubated at 28 wk 3 d, prone ventilation (× 1), extubated on HD 19Intubated at 30 wk 5d, bacteremia, extubated HD 15, discharged HD 20Intubated at 25 wk 2 d, extubation HD 6 with reintubation, final extubation HD 8, discharged HD 13DeliveryYesNoYesYesNoIndicationMaternalMaternalMaternalGA at delivery31 wk 4 d30 wk 2 d31 wk 3 dModeCesareanCesareanCesareanNeonatal birthweight (g)150021101845Apgar score9, 98, 92, 4, 4Neonatal SARS-CoV-2 PCR result at 24 HOLNegativeNegativeNegativeACE, angiotensin-converting-enzyme, BMI, body mass index; COVID-19, coronavirus disease 2019; CRP, c-reactive protein; GA, gestational age; HCQ, hydroxychloroquine; HD, hospital day; HOL, hours of life; PCR, polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.Hirshberg. Care of critically ill pregnant patients with COVID-19. Am J Obstet Gynecol 2020. Open table in a new tab ACE, angiotensin-converting-enzyme, BMI, body mass index; COVID-19, coronavirus disease 2019; CRP, c-reactive protein; GA, gestational age; HCQ, hydroxychloroquine; HD, hospital day; HOL, hours of life; PCR, polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. Hirshberg. Care of critically ill pregnant patients with COVID-19. Am J Obstet Gynecol 2020. Case 1 involved a 28-year-old G1P0 with chronic kidney disease and hypertension. She developed worsening dyspnea on the sixth day of outpatient monitoring after a confirmed diagnosis of COVID-19. She presented to the hospital with fever and dyspnea at 31 weeks of gestation. Chest imaging showed multifocal pneumonia, and she required O2 at a flow rate of 2 L/min to maintain her oxygen saturation levels above 95%. On hospital day (HD) 3, her oxygen saturation dropped to 80%, and she required additional O2 at a flow rate of 6 L/min. Antenatal corticosteroids were administered, and based on a concern for further decompensation, the decision was made to proceed with intubation and delivery under controlled settings. She had an uncomplicated cesarean delivery and recovered from acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU). She completed courses of hydroxychloroquine and remdesivir and was ultimately extubated on postoperative day 17 after gradual weaning. She was discharged 4 days later after 2 consecutive negative SARS-CoV-2 test results. Case 2 involved a 33-year-old G6P5005 with mild asthma who presented, at 26 weeks of gestation, with worsening fevers and respiratory symptoms for 10 days. Her O2 saturation level was 83%, and she required O2 at a flow rate of 5 L/min. Chest imaging revealed multifocal pneumonia. Testing for SARS-CoV-2 delivered a positive result. She was transferred to the ICU with an increasing demand for oxygen supplementation, and she was intubated several hours later. Based on the early gestational age and maternal acuity, continuous fetal heart monitoring was not initiated. Administration of antenatal corticosteroids was deferred owing to a concern for worsening viral shedding. Her course has been complicated by ARDS, septic shock, and inferior vena cava thrombus treated with anticoagulants. She had completed courses of hydroxychloroquine and remdesivir, as well as antibiotic courses for superimposed bacterial pneumonia. She also required vasopressor support and stress dose steroids for sepsis (using dexamethasone for adjunctive fetal benefit). She was placed in the prone position for worsening hypoxemic respiratory failure and acidosis on HD 3 and 8, with improvement, and a cannula was put in place for the treatment of extracorporeal membrane oxygenation (ECMO) in the case of further deterioration. She remains critically ill, although ventilation support has been reduced to a tracheostomy collar. Daily fetal heart tone checks in conjunction with intermittent biophysical profiles, have delivered positive results to date. Delivery is being considered, but the significant improvements in maternal health and early gestational age warrant deferral. Case 3 involved a 39-year-old G4P3003 with hypertension, obstructive sleep apnea, and insulin-dependent diabetes who presented, at 28 weeks’ gestation, with a persistent fever that had been present for 2 weeks, a cough, and worsening dyspnea. She was febrile, tachypneic, and hypoxic (with an O2 saturation level of 86%) on arrival, had a positive result for SARS-CoV-2 testing, and displayed multifocal pneumonia based on chest imaging. She was transferred to the ICU for worsening dyspnea, where she was intubated and subsequently transferred to our tertiary care facility for ARDS. She was treated with antibiotics for superimposed bacterial pneumonia and received hydroxychloroquine, remdesivir, and anticoagulation therapy. She was placed in the prone position on HD 7 for worsening hypoxemic respiratory failure, at which point antenatal corticosteroids were administered. The results of fetal evaluation through daily heart tone checks were normal. She underwent an uncomplicated repeat cesarean delivery on HD 15, at 30 weeks and 2 days’ gestation, under controlled mechanical ventilation for persistent, but stable, critical illness. She was extubated on postoperative day 5 (HD 20) and transitioned to a high-flow nasal cannula. Case 4 involved a 27-year-old G3P0202 who presented, at 30 weeks of gestation, with 4 days of myalgias, fatigue, a productive cough, and fever. She was tachycardic (with a heart rate greater than 130 beats/min) on arrival, and chest imaging revealed multifocal pneumonia. A test for SARS-CoV-2 was positive. She began receiving hydroxychloroquine and was transferred to the ICU for impending respiratory failure. She was intubated 2 days later, at which time she also received betamethasone and started receiving a course of remdesivir. The results of daily fetal heart tone monitoring were normal. Her blood cultures were positive for Proteus mirabilis, and she was subsequently treated with broad spectrum antibiotics for superimposed pneumonia. Attempts to wean her from supporting ventilation were unsuccessful, and arterial blood gas revealed persistent acidemia. She underwent an uncomplicated primary cesarean delivery on HD 9 because of her declining respiratory status. She was extubated on HD 15 and discharged after being on room air for 5 days. Case 5 involved a 35-year-old G4P2012 who presented, at 25 weeks’ gestation, with 9 days of fever, cough, and progressive dyspnea. She was febrile and tachypneic, with chest imaging demonstrating multifocal pneumonia. She was admitted for suspected COVID-19–related pneumonia, treated with hydroxychloroquine and antibiotics, and transferred to the ICU for impending respiratory failure and intubation. The results of 2 initial SARS-CoV-2 tests were negative, although she remained critically ill and required vasopressor support. Empirical oseltamivir therapy was initiated, and owing to an increasing probability of delivery, antenatal corticosteroids were administered. A third inpatient SARS-CoV-2 test (from tracheal aspirate) delivered a positive result, and remdesivir was started. She was successfully extubated on HD 8, weaned to room air on HD 11, and discharged 2 days later with close outpatient follow-ups. The number of pregnant patients requiring critical care thus far appears to be higher in Philadelphia hospitals than in other published accounts. A report, from Singapore, that was published during the early stages of the pandemic, chronicled a total of 55 published cases of pregnant patients with COVID-19 disease, with no reports of mortality and only 1 report of a requirement for mechanical ventilation.3Dashraath P. Wong J.L.J. Lim M.X.K. et al.Coronavirus disease 2019 (COVID-19) pandemic and pregnancy.Am J Obstet Gynecol. 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (786) Google Scholar Other reviews have uncovered only 3 additional cases of critical illness linked to COVID-19 during pregnancy.4Mullins E. Evans D. Viner R.M. O’Brien P. Morris E. Coronavirus in pregnancy and delivery: rapid review.Ultrasound Obstet Gynecol. 2020; ([Epub ahead of print])Crossref PubMed Scopus (325) Google Scholar,5Zaigham M. Andersson O. Maternal and perinatal outcomes with COVID-19: a systematic review of 108 pregnancies.Acta Obstet Gynecol Scand. 2020; ([Epub ahead of print])Crossref PubMed Scopus (524) Google Scholar The early American experience with COVID-19 in pregnancy was characterized by a case series from New York that reported on a total of 2 critical cases, both postpartum.1Breslin N. BC Baptiste C. Gyamfi-Bannerman C. et al.COVID-19 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals.Am J Obstet Gynecol MFM. 2020; ([Epub ahead of print])Google Scholar