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Delivery for respiratory compromise among pregnant women with coronavirus disease 2019

      Objective

      Although rapid recourse to delivery after failed cardiopulmonary resuscitation has been shown to improve outcomes of pregnant patients experiencing cardiac arrest,
      • Pacheco L.D.
      • Saade G.
      • Hankins G.D.
      • Clark S.L.
      Society for Maternal-Fetal Medicine
      Amniotic fluid embolism: diagnosis and management.
      ,
      • Jeejeebhoy F.M.
      • Zelop C.M.
      • Lipman S.
      • et al.
      Cardiac arrest in pregnancy: a scientific statement from the American Heart Association.
      it is not known whether delivery improves or compromises the outcome of patients with coronavirus disease 2019 (COVID-19) experiencing respiratory failure.
      Society for Maternal-Fetal Medicine
      Management considerations for pregnant patients with COVID-19.
      ,
      Society for Maternal-Fetal Medicine, Society for Obstetric and Anesthesia and Perinatology
      Labor and delivery COVID-19 considerations.
      This study aimed to evaluate the safety and utility of delivery of pregnant women with COVID-19 needing respiratory support.

      Study Design

      This is a retrospective observational study of pregnant women diagnosed with COVID-19 via polymerase chain reaction who developed severe disease (defined per previous publications
      Society for Maternal-Fetal Medicine
      Management considerations for pregnant patients with COVID-19.
      ). A subset of these cases was previously presented but without details on the effect of delivery on the disease.
      • London V.
      • McLaren Jr., R.
      • Atallah F.
      • et al.
      The relationship between status at presentation and outcomes among pregnant women with COVID-19.
      The study was exempted by the institutional review board.

      Results

      Of 125 confirmed cases of COVID-19, 12 (9.6%) had severe disease (Table). Among the 12 patients, the condition of 3 patients improved after receiving transient respiratory support in the hospital, and they were discharged home (1 subsequently returned in preterm labor and gave birth by cesarean delivery 2 weeks later). Of the remaining 9 patients who continued to need respiratory support, 7 (77.8%) had iatrogenic preterm deliveries (6 by cesarean delivery) for maternal respiratory distress (needing increasing levels of respiratory support without improved oxygen saturation), 1 had an early term delivery because of premature rupture of membranes, and 1, at 30 weeks’ gestation, was admitted to the intensive care unit with high-flow nasal cannula for 3 weeks.
      TableCharacteristics and outcomes of pregnant women with severe COVID-19
      Patient number123456789101112
      Age (y)443334283732342532243029
      BMI (kg/m2)28.430.336.025.929.329.330.832.541.031.042.029.4
      Medical historyNoneNonePregestational diabetes, hepatitis BNoneGestational diabetes A2NoneGestational diabetes A1NoneChronic hypertensionNoneNoneNone
      Gestational age at initial symptom294334353310285315372330260346260253
      Mode of deliveryCesareanCesareanCesareanCesareanCesareanCesareanVaginalCesareanVaginal
      IndicationMaternal respiratory distressMaternal respiratory distressMaternal respiratory distressMaternal respiratory distressMonochorionic diamniotic twinsMaternal respiratory distressEarly term PROMMaternal respiratory distressMaternal respiratory distress
      Gestational age at delivery314353362324314316372344351
      Respiratory supportNonrebreatherSimple nasal cannulaMechanical ventilationNonrebreatherSimple nasal cannulaSimple nasal cannulaSimple nasal cannulaSimple nasal cannulaSimple nasal cannulaSimple nasal cannulaHigh-flow nasal cannulaSimple nasal cannula
      ICUNoNoYesNoNoNoNoNoNoNoYesNo
      LOS (d)94268773938X5
      LOS after delivery (d)7426544385
      BMI, body mass index; COVID-19, coronavirus disease 2019; ICU, intensive care unit; LOS, length of hospital stay; PROM, premature rupture of membranes; X, currently admitted for 15 days as of May 1, 2020.
      Mclaren. Delivery for respiratory compromise among pregnant women with COVID-19. Am J Obstet Gynecol 2020.
      Of the 8 patients delivering with maternal respiratory distress, 7 did not require intubation, and 1 was intubated for emergent cesarean delivery and remained on a ventilator for 19 days. Among the nonintubated, 4 had an improvement in oxygenation within 2 hours after delivery, 2 required less respiratory support, and 2 were taken completely off respiratory support. None of the other 3 patients required an increased level of respiratory support, and they were off of all support between 4 and 7 days after delivery.

      Conclusion

      Delivery did not worsen the respiratory status of women with persistent oxygen desaturation and the need for increasing respiratory support. Among women not needing a ventilator, the return to normal respiratory status after delivery occurred within hours to days. However, the 1 patient who was intubated intraoperatively took longer to recover. It is possible that delivery may be less salutary when damage to the lungs is sufficient to warrant intubation. This series suggests that maternal respiratory distress should not be a contraindication to delivery.
      As noted in a recent Society for Maternal-Fetal Medicine and Society for Obstetric Anesthesia and Perinatology guideline, it is not known whether uterine decompression improves respiratory status; we are unable to shed light on that issue.
      Society for Maternal-Fetal Medicine, Society for Obstetric and Anesthesia and Perinatology
      Labor and delivery COVID-19 considerations.
      Although we saw no harm, we cannot be certain that delivery per se caused the improvement we observed or whether a similar outcome could have been achieved with ongoing respiratory support (although 1 of 3 patients managed conservatively remained on respiratory support for 3 weeks). In summary, although more data on the effects of delivery are needed, we have shown in a small series that women with COVID-19 requiring respiratory support fared well when they underwent delivery.

      References

        • Pacheco L.D.
        • Saade G.
        • Hankins G.D.
        • Clark S.L.
        • Society for Maternal-Fetal Medicine
        Amniotic fluid embolism: diagnosis and management.
        Am J Obstet Gynecol. 2016; 215: B16-B24
        • Jeejeebhoy F.M.
        • Zelop C.M.
        • Lipman S.
        • et al.
        Cardiac arrest in pregnancy: a scientific statement from the American Heart Association.
        Circulation. 2015; 132: 1747-1773
        • Society for Maternal-Fetal Medicine
        Management considerations for pregnant patients with COVID-19.
        (Available at:)
        • Society for Maternal-Fetal Medicine, Society for Obstetric and Anesthesia and Perinatology
        Labor and delivery COVID-19 considerations.
        (Available at:)
        • London V.
        • McLaren Jr., R.
        • Atallah F.
        • et al.
        The relationship between status at presentation and outcomes among pregnant women with COVID-19.
        Am J Perinatol. 2020; ([Epub ahead of print])