Objective
Although rapid recourse to delivery after failed cardiopulmonary resuscitation has been shown to improve outcomes of pregnant patients experiencing cardiac arrest,
1
,2
it is not known whether delivery improves or compromises the outcome of patients with coronavirus disease 2019 (COVID-19) experiencing respiratory failure.3
,Society for Maternal-Fetal Medicine
Management considerations for pregnant patients with COVID-19.
Management considerations for pregnant patients with COVID-19.
https://s3.amazonaws.com/cdn.smfm.org/media/2334/SMFM_COVID_Management_of_COVID_pos_preg_patients_4-29-20_final.pdf
Date accessed: April 30, 2020
4
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
3
). A subset of these cases was previously presented but without details on the effect of delivery on the disease.Society for Maternal-Fetal Medicine
Management considerations for pregnant patients with COVID-19.
Management considerations for pregnant patients with COVID-19.
https://s3.amazonaws.com/cdn.smfm.org/media/2334/SMFM_COVID_Management_of_COVID_pos_preg_patients_4-29-20_final.pdf
Date accessed: April 30, 2020
5
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 number | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Age (y) | 44 | 33 | 34 | 28 | 37 | 32 | 34 | 25 | 32 | 24 | 30 | 29 |
| BMI (kg/m2) | 28.4 | 30.3 | 36.0 | 25.9 | 29.3 | 29.3 | 30.8 | 32.5 | 41.0 | 31.0 | 42.0 | 29.4 |
| Medical history | None | None | Pregestational diabetes, hepatitis B | None | Gestational diabetes A2 | None | Gestational diabetes A1 | None | Chronic hypertension | None | None | None |
| Gestational age at initial symptom | 294 | 334 | 353 | 310 | 285 | 315 | 372 | 330 | 260 | 346 | 260 | 253 |
| Mode of delivery | Cesarean | Cesarean | Cesarean | Cesarean | Cesarean | Cesarean | Vaginal | Cesarean | — | Vaginal | — | — |
| Indication | Maternal respiratory distress | Maternal respiratory distress | Maternal respiratory distress | Maternal respiratory distress | Monochorionic diamniotic twins | Maternal respiratory distress | Early term PROM | Maternal respiratory distress | — | Maternal respiratory distress | — | — |
| Gestational age at delivery | 314 | 353 | 362 | 324 | 314 | 316 | 372 | 344 | — | 351 | — | — |
| Respiratory support | Nonrebreather | Simple nasal cannula | Mechanical ventilation | Nonrebreather | Simple nasal cannula | Simple nasal cannula | Simple nasal cannula | Simple nasal cannula | Simple nasal cannula | Simple nasal cannula | High-flow nasal cannula | Simple nasal cannula |
| ICU | No | No | Yes | No | No | No | No | No | No | No | Yes | No |
| LOS (d) | 9 | 4 | 26 | 8 | 7 | 7 | 3 | 9 | 3 | 8 | X | 5 |
| LOS after delivery (d) | 7 | 4 | 26 | 5 | 4 | 4 | 3 | 8 | — | 5 | — | — |
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.
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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
- Amniotic fluid embolism: diagnosis and management.Am J Obstet Gynecol. 2016; 215: B16-B24
- Cardiac arrest in pregnancy: a scientific statement from the American Heart Association.Circulation. 2015; 132: 1747-1773
- Management considerations for pregnant patients with COVID-19.(Available at:)https://s3.amazonaws.com/cdn.smfm.org/media/2334/SMFM_COVID_Management_of_COVID_pos_preg_patients_4-29-20_final.pdfDate accessed: April 30, 2020
- Labor and delivery COVID-19 considerations.(Available at:)
- The relationship between status at presentation and outcomes among pregnant women with COVID-19.Am J Perinatol. 2020; ([Epub ahead of print])
Article info
Publication history
Published online: May 23, 2020
Footnotes
The authors report no conflict of interest.
This communication has been published in the middle of the COVID-19 pandemic and is available via expedited publication to assist patients and healthcare providers.
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
