Mechanical ventilation and prone positioning in pregnant patients with severe COVID-19 pneumonia: experience at a quaternary referral center

Peripartum Infections: A Position Statement of the Indian Society of Critical Care Medicine

This position statement reviews the evidence and rationale for the management of severe peripartum infections with a special focus on tropical infections and is tailored for resource-limited settings.

How to cite this article

Samavedam S, Sodhi K, Anand P, Bajwa SJS, Karnad DR, Karanth S, et al. Peripartum Infections: A Position Statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2024;28(S2):S92-S103.

COVID-19 therapeutics for the pregnant patient

SARS-CoV-2 infection can cause severe disease among pregnant persons. Pregnant persons were not included in initial studies of therapeutics for COVID-19, but cumulative experience demonstrates that most are safe for pregnant persons and the fetus, and effective for prevention or treatment of severe COVID-19.

Maternal-Fetal Results of COVID-19-Infected Pregnant Women Treated with Extracorporeal Membrane Oxygenation: A Descriptive Report

OBJECTIVE

COVID-19 infection may produce severe pneumonia, mainly in the adult population. Pregnant women with severe pneumonia are at high risk of developing complications, and conventional therapy sometimes fails to reverse hypoxemia. Therefore, extracorporeal membrane oxygenation (ECMO) is an option in cases with refractory hypoxemic respiratory failure. This study aims to evaluate the maternal-fetal risk factors, clinical characteristics, complications, and outcomes of 11 pregnant or peripartum patients with COVID-19 treated with ECMO.

STUDY DESIGN

This is a retrospective descriptive study of 11 pregnant women undergoing ECMO therapy during the COVID-19 pandemic.

RESULTS

In our cohort, four patients underwent ECMO during pregnancy (36.3%) and 7 during the postpartum period. Initially, they started on venovenous ECMO, and three patients were required to change modality due to clinical conditions. In total, 4/11 pregnant women (36.3%) died. We established two periods that differed in the implementation of a standardized care model for reducing associated morbidities and mortality. Neurological complications were responsible for most deaths. Regarding fetal outcomes at early-stage pregnancies on ECMO (4), we report three stillbirths (75%), and one newborn (twin pregnancy) survived and had a favorable evolution.

CONCLUSION

At later-stage pregnancies, all newborns survived, and we did not identify any vertical infection. ECMO therapy is an alternative for pregnant women with severe hypoxemic respiratory failure due to COVID-19, and may improve maternal and neonatal results. Regarding fetal outcomes, the gestational age played a definitive role. However, the main complications reported in our series and others are neurological. It is essential to develop novel, future interventions to prevent these complications.

Critical care, maternal and neonatal outcomes of pregnant women with COVID-19 admitted to eight intensive care units during the wildtype, alpha and delta waves of the pandemic across the North West of England-a retrospective review

INTRODUCTION

Few studies have described obstetric and critical care outcomes in pregnant women with COVID-19 needing intensive care unit (ICU) admission.

MATERIAL AND METHODS

Obstetric and critical care outcomes of COVID-19 women admitted to eight ICUs from April 1, 2020 to September 15, 2021, in the North West of England were retrospectively analyzed. Women admitted to ICU were assigned to three groups: antepartum women discharged from ICU prior to delivery (antepartum ICU-discharged group), antepartum women who had expedited delivery (antepartum ICU-delivered group) and a postpartum group. Our aims were to describe maternal characteristics and assess how delivery influenced the obstetric and critical care outcomes in these women.

RESULTS

During the study period, 615 women tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of whom 62 (10.1%) needed ICU admission due to symptomatic COVID-19. Pregnancy loss (3.2%) was recorded in two women. Detailed obstetric and critical outcomes from 60 women are reported. Nine antepartum women (15%) admitted to ICU were discharged and continued their pregnancy, 13 antepartum women (21.7%) had expedited delivery by cesarean birth after ICU admission and 38 (63.3%) women were admitted to ICU during the postpartum period. Antepartum ICU-discharged women contracted the SARS-CoV-2 at an earlier median gestational age (23 weeks; p = 0.0003) and needed ICU admission at an earlier median gestational age (28 weeks, p = 0.03) compared with antepartum ICU-delivered (28 and 32 weeks) and postpartum women (35.5 and 36 weeks). Antepartum ICU-discharged women had the lowest rate of mechanical ventilation receipt (11.1%) compared with antepartum ICU-delivered women (52.3%) and postpartum women (44.3%) but the difference was not statistically significant (p = 0.13). No significant differences were observed in the frequency and severity of critical care complications in the antepartum ICU-discharged, antepartum-ICU delivered and postpartum women.

CONCLUSIONS

Of the women admitted to ICU antepartum, 40% were discharged while remaining pregnant and 60% had expedited delivery. Antepartum women who were discharged from ICU without giving birth may receive lower rates of mechanical ventilation than those who delivered in ICU or admitted postpartum; however, further studies are needed to confirm or refute this association.

COVID-19 and Pregnancy: An Updated Review about Evidence-Based Therapeutic Strategies

The COVID-19 pandemic posed a significant challenge for clinicians in managing pregnant women, who were at high risk of virus transmission and severe illness. While the WHO declared in May 2023 that COVID-19 is no longer a public health emergency, it emphasized that it remains a global health threat. Despite the success of vaccines, the possibility of new pandemic waves due to viral mutations should be considered. Ongoing assessment of the safety and effectiveness of pharmacological therapies is crucial in clinical practice. This narrative review summarizes the evidence-based therapeutic strategies for pregnant women with COVID-19, considering over three years of pandemic experience. The review discusses the safety and effectiveness of various drug regimens (antivirals, anticoagulants, corticosteroids, immunoglobulins, monoclonal antibodies, and therapeutic gases) and procedures (prone positioning and extracorporeal membrane oxygenation). Drugs with contraindications, inefficacy during pregnancy, or unknown adverse effects were excluded from our evaluation. The aim is to provide healthcare professionals with a comprehensive guide for managing pregnant women with COVID-19 based on lessons learned from the pandemic outbreak.

Pregnancy and Severe ARDS with COVID-19: Epidemiology, Diagnosis, Outcomes and Treatment

Pregnancy-related acute respiratory distress syndrome (ARDS) is fast becoming a growing and clinically relevant subgroup of ARDS amidst global outbreaks of various viral respiratory pathogens that include H1N1-influenza, severe acute respiratory syndrome (SARS), middle east respiratory syndrome (MERS), and the most recent COVID-19 pandemic. Pregnancy is a risk factor for severe viral-induced ARDS and commonly associated with poor maternal and fetal outcomes including fetal growth-restriction, preterm birth, and spontaneous abortion. Physiologic changes of pregnancy further compounded by mechanical and immunologic alterations are theorized to impact the development of ARDS from viral pneumonia. The COVID-19 sub-phenotype of ARDS share overlapping molecular features of maternal pathogenicity of pregnancy with respect to immune-dysregulation and endothelial/microvascular injury (i.e., preeclampsia) that may in part explain a trend toward poor maternal and fetal outcomes seen with severe COVID-19 maternal infections. To date, current ARDS diagnostic criteria and treatment management fail to include and consider physiologic adaptations that are unique to maternal physiology of pregnancy and consideration of maternal-fetal interactions. Treatment focused on lung-protective ventilation strategies have been shown to improve clinical outcomes in adults with ARDS but may have adverse maternal-fetal interactions when applied in pregnancy-related ARDS. No specific pharmacotherapy has been identified to improve outcomes in pregnancy with ARDS. Adjunctive therapies aimed at immune-modulation and anti-viral treatment with COVID-19 infection during pregnancy have been reported but data in regard to its efficacy and safety is currently lacking.

Ventilatory Parameters in Obstetric Patients With COVID-19 and Impact of Delivery: A Multicenter Prospective Cohort Study

BACKGROUND

Current evidence on obstetric patients requiring advanced ventilatory support and impact of delivery on ventilatory parameters is retrospective, scarce, and controversial.

RESEARCH QUESTION

What are the ventilatory parameters for obstetric patients with COVID-19 and how does delivery impact them? What are the risk factors for invasive mechanical ventilation (IMV) and for maternal, fetal, and neonatal mortality?

STUDY DESIGN AND METHODS

Prospective, multicenter, cohort study including pregnant and postpartum patients with COVID-19 requiring advanced ventilatory support in the ICU.

RESULTS

Ninety-one patients were admitted to 21 ICUs at 29.2 ± 4.9 weeks; 63 patients (69%) delivered in ICU. Maximal ventilatory support was as follows: IMV, 69 patients (76%); high-flow nasal cannula, 20 patients (22%); and noninvasive mechanical ventilation, 2 patients (2%). Sequential Organ Failure Assessment during the first 24 h (SOFA₂₄) score was the only risk factor for IMV (OR, 1.97; 95% CI, 1.29-2.99; P = .001). Respiratory parameters at IMV onset for pregnant patients were: mean ± SD plateau pressure (PP), 24.3 ± 4.5 cm H₂O; mean ± SD driving pressure (DP), 12.5 ± 3.3 cm H₂O; median static compliance (SC), 31 mL/cm H₂O (interquartile range [IQR], 26-40 mL/cm H₂O); and median Pao₂ to Fio₂ ratio, 142 (IQR, 110-176). Respiratory parameters before (< 2 h) and after (≤ 2 h and 24 h) delivery were, respectively: mean ± SD PP, 25.6 ± 6.6 cm H₂O, 24 ± 6.7 cm H₂O, and 24.6 ± 5.2 cm H₂O (P = .59); mean ± SD DP, 13.6 ± 4.2 cm H₂O, 12.9 ± 3.9 cm H₂O, and 13 ± 4.4 cm H₂O (P = .69); median SC, 28 mL/cm H₂O (IQR, 22.5-39 mL/cm H₂O), 30 mL/cm H₂O (IQR, 24.5-44 mL/cm H₂O), and 30 mL/cm H₂O (IQR, 24.5-44 mL/cm H₂O; P = .058); and Pao₂ to Fio₂ ratio, 134 (IQR, 100-230), 168 (IQR, 136-185), and 192 (IQR, 132-232.5; P = .022). Reasons for induced delivery were as follows: maternal, 43 of 71 patients (60.5%); maternal and fetal, 21 of 71 patients (29.5%); and fetal, 7 of 71 patients (9.9%). Fourteen patients (22.2%) continued pregnancy after ICU discharge. Risk factors for maternal mortality were BMI (OR, 1.10; 95% CI, 1.006-1.204; P = .037) and comorbidities (OR, 4.15; 95% CI, 1.212-14.20; P = .023). Risk factors for fetal or neonatal mortality were gestational age at delivery (OR, 0.67; 95% CI, 0.52-0.86; P = .002) and SOFA₂₄ score (OR, 1.53; 95% CI, 1.13-2.08; P = .006).

INTERPRETATION

Contrary to expectations, pregnant patient lung mechanics were similar to those of the general population with COVID-19 in the ICU. Delivery was induced mainly for maternal reasons, but did not change ventilatory parameters other than Pao₂ to Fio₂ ratio. SOFA₂₄ score was the only risk factor for IMV. Maternal mortality was associated independently with BMI and comorbidities. Risk factors for fetal and neonatal mortality were SOFA₂₄ score and gestational age at delivery.

Treatment of pregnant and early postpartum women with severe and critical COVID-19: experience at a tertiary center

BACKGROUND

The management of acute respiratory failure during pregnancy is a poorly defined issue in the literature, especially regarding the use of the prone position and the appropriate time for delivery. This study describes our experience in treating pregnant and postpartum women with severe or critical coronavirus disease 2019 (COVID-19).

MATERIALS AND METHODS

This descriptive retrospective study included 25 pregnant and 4 postpartum women admitted to an ICU due to respiratory complications from COVID-19 from June 2020 to August 2021.

RESULTS

The mean maternal age was 33.6 years, and the median gestational age (GA) at admission was 33 weeks. Obesity was the most common comorbidity. The median time between symptom onset and ICU admission was 10 days, while the median length of ICU stay was 14 days. Invasive mechanical ventilation (IMV) was required in 16 (55.2%) patients for a median time of 16.5 days. Prone positioning (PP) was performed in 68.7% of the patients on IMV, and resulted in an expressive increase in arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio). Eleven (44%) pregnant women delivered during their ICU stay for obstetric or fetal reasons: of these, 2 (18%) developed postpartum hemorrhagic shock and 1 (9%) developed abdominal wall infection. None of the 25 pregnant women underwent delivery due to acute respiratory failure or in an attempt to avoid intubation. There were 2 fetal deaths, but no maternal or neonatal deaths.

CONCLUSION

We observed favorable outcomes in pregnant and postpartum women with severe and critical COVID-19 admitted to our institution. This finding reinforces the effectiveness of PP in the treatment of hypoxemic respiratory failure secondary to COVID-19 in pregnant women undergoing IMV, and suggests that gestation should only be interrupted in cases of obstetric and fetal complications, provided the patient is stable, or when hypoxemia is refractory to PP.

Delivery decision in pregnant women rescued by ECMO for severe ARDS: a retrospective multicenter cohort study

Background

Although rarely addressed in the literature, a key question in the care of critically pregnant women with severe acute respiratory distress syndrome (ARDS), especially at the time of extracorporeal membrane oxygenation (ECMO) decision, is whether delivery might substantially improve the mother’s and child’s conditions. This multicenter, retrospective cohort aims to report maternal and fetal short- and long-term outcomes of pregnant women with ECMO-rescued severe ARDS according to the timing of the delivery decision taken before or after ECMO cannulation.

Methods

We included critically ill women with ongoing pregnancy or within 15 days after a maternal/child-rescue-aimed delivery supported by ECMO for a severe ARDS between October 2009 and August 2021 in four ECMO centers. Clinical characteristics, critical care management, complications, and hospital discharge status for both mothers and children were collected. Long-term outcomes and premature birth complications were assessed.

Results

Among 563 women on venovenous ECMO during the study period, 11 were cannulated during an ongoing pregnancy at a median (range) of 25 (21–29) gestational weeks, and 13 after an emergency delivery performed at 32 (17–39) weeks of gestation. Pre-ECMO PaO₂/FiO₂ ratio was 57 (26–98) and did not differ between the two groups. Patients on ECMO after delivery reported more major bleeding (46 vs. 18%, p = 0.05) than those with ongoing pregnancy. Overall, the maternal hospital survival was 88%, which was not different between the two groups. Four (36%) of pregnant women had a spontaneous expulsion on ECMO, and fetal survival was higher when ECMO was set after delivery (92% vs. 55%, p = 0.03). Among newborns alive, no severe preterm morbidity or long-term sequelae were reported.

Conclusion

Continuation of the pregnancy on ECMO support carries a significant risk of fetal death while improving prematurity-related morbidity in alive newborns with no difference in maternal outcomes. Decisions regarding timing, place, and mode of delivery should be taken and regularly (re)assess by a multidisciplinary team in experienced ECMO centers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04189-5.

Increased maternal mortality in unvaccinated SARS-CoV-2 infected pregnant patients

The aim of this study was to demonstrate the poor prognosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in unvaccinated pregnant women. In this retrospective study, the clinical and laboratory parameters of 26 pregnant or immediately postpartum patients, who were hospitalised and needed intensive care unit (ICU) follow-up due to coronavirus disease 2019 (COVID-19) infection were reported. All pregnant patients who followed up in the ICU were unvaccinated. The mortality rate was calculated as 34.62% in the patients included in the study who were admitted to the ICU. Among patients hospitalised in the ICU, the maternal mortality and stillbirth rates associated with COVID-19 infection were found to be 156.28/100,000 and 11.54%, respectively. Preterm birth occurred in 58.33% of the patients who delivered. 79.17% of the patients were delivered by caesarean section. Lymphopenia, high ferritin, interleukin-6, lactate dehydrogenase, D-dimer and C-reactive protein values were found to be associated with mortality. The course of pregnant patients with COVID-19 infection is not always predictable. Clinical and laboratory data should be evaluated in combination for disease prognosis. Adequate information should be given about the importance of vaccination.Impact StatementWhat is already known on this subject? The SARS-CoV-2 infection has caused a public health crisis worldwide. As a result of studies on coronavirus disease 2019 (COVID-19) infected pregnant women, it was observed that there was an increase in maternal and perinatal mortality. There has been an increase in intensive care unit (ICU) admissions, especially after patients infected with the Delta variant. The pandemic continues with an unpredictable course of the new variants.What do the results of this study add? Compared to the pre-pandemic period, COVID-19 infection caused a more than 10-fold increase in maternal mortality, particularly after the Delta variant. In intensive care follow-up, low lymphocyte count, high lactate dehydrogenase, D-dimer, C-reactive protein, ferritin and interleukin-6 values are indicators of poor prognosis.What are the implications of these findings for clinical practice and/or further research? COVID-19 infection causes increased maternal mortality. Considering that all of the patients admitted to the ICU in our study were unvaccinated, pregnant women should be encouraged to get vaccinated.

Management and outcomes of pregnant women admitted to intensive care unit for severe pneumonia related to SARS-CoV-2 infection: the multicenter and international COVIDPREG study

Purpose

Management and outcomes of pregnant women with coronavirus disease 2019 (COVID-19) admitted to intensive care unit (ICU) remain to be investigated.

Methods

A retrospective multicenter study conducted in 32 ICUs in France, Belgium and Switzerland. Maternal management as well as maternal and neonatal outcomes were reported.

Results

Among the 187 pregnant women with COVID-19 (33 ± 6 years old and 28 ± 7 weeks’ gestation), 76 (41%) were obese, 12 (6%) had diabetes mellitus and 66 (35%) had pregnancy-related complications. Standard oxygenation, high-flow nasal oxygen therapy (HFNO) and non-invasive ventilation (NIV) were used as the only oxygenation technique in 41 (22%), 55 (29%) and 18 (10%) patients, respectively, and 73 (39%) were intubated. Overall, 72 (39%) patients required several oxygenation techniques and 15 (8%) required venovenous extracorporeal membrane oxygenation. Corticosteroids and tocilizumab were administered in 157 (84%) and 25 (13%) patients, respectively. Awake prone positioning or prone positioning was performed in 49 (26%) patients. In multivariate analysis, risk factors for intubation were obesity (cause-specific hazard ratio (CSH) 2.00, 95% CI (1.05–3.80), p = 0.03), term of pregnancy (CSH 1.07, 95% CI (1.02–1.10), per + 1 week gestation, p = 0.01), extent of computed tomography (CT) scan abnormalities > 50% (CSH 2.69, 95% CI (1.30–5.60), p < 0.01) and NIV use (CSH 2.06, 95% CI (1.09–3.90), p = 0.03). Delivery was required during ICU stay in 70 (37%) patients, mainly due to maternal respiratory worsening, and improved the driving pressure and oxygenation. Maternal and fetal/neonatal mortality rates were 1% and 4%, respectively. The rate of maternal and/or neonatal complications increased with the invasiveness of maternal respiratory support.

Conclusion

In ICU, corticosteroids, tocilizumab and prone positioning were used in few pregnant women with COVID-19. Over a third of patients were intubated and delivery improved the driving pressure.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-022-06833-8.

Effect of Fetal Delivery on Pao2/Fio2 Ratio During Mechanical Ventilation in Parturients With COVID-19: A Case Series

It is controversial whether fetal delivery improves maternal oxygenation during mechanical ventilation. We evaluated maternal arterial partial pressure of oxygen (Pao2) to fractional oxygen concentration (Fio2) (P/F) ratios before and after delivery in this series of 15 parturients with coronavirus disease 2019 (COVID-19). Compared to the immediate postpartum period, P/F ratio was increased at 48 hours (212 ± 101 vs 271 ± 90; P = .006). Linear regression demonstrated improvement in P/F ratio during the study period (slope, 3.1; 95% confidence interval [CI], 0.87-5.34; P = .007), although predelivery and postdelivery periods separately did not exhibit any specific trend. Five patients required emergent bedside delivery. We discuss numerous considerations guiding delivery planning during mechanical ventilation.

Managing COVID-19 in pregnant women

Pregnant women are no more likely to contract coronavirus disease 2019 (COVID-19) than the background population and two-thirds of those testing positive are asymptomatic [1, 2]. Risk factors for severe infection reflect those outside pregnancy and include being unvaccinated, aged >35 years, having a body mass index >25 kg·m⁻², having a medical comorbidity, being in the Black, Asian and Minority Ethnicity (BAME) population, and socioeconomic deprivation [1]. Pregnant women who develop moderate/severe disease are more likely to require hospitalisation and critical care admission, particularly in the third trimester [1].

Principles of management of COVID-19 in the general population apply in pregnancy with few exceptions. Clinical inertia can lead to preventable morbidity and mortality. COVID-19 vaccines are safe and should be recommended at any stage of pregnancy.https://bit.ly/3Rj8nWr

Diagnosis and management of covid-19 in pregnancy

Pregnant women with covid-19 are at greater risk of severe disease than their non-pregnant peers, and yet they are frequently denied investigations or treatments because of unfounded concerns about risk to the fetus. The basic principles of diagnosing and managing covid-19 are the same as for non-pregnant patients, and a multidisciplinary, expert team approach is essential to ensure optimal care. During pregnancy, treatment with corticosteroids should be modified to use non-fluorinated glucocorticoids. Il-6 inhibitors and monoclonal antibodies, together with specific antiviral therapies, may also be considered. Prophylaxis against venous thromboembolism is important. Women may require respiratory support with oxygen, non-invasive ventilation, ventilation in a prone position (either awake or during invasive ventilation), intubation and ventilation, and extracorporeal membrane oxygenation (ECMO). Pregnancy is not a contraindication for any of these supportive therapies, and the criteria for providing them are the same as in the general population. Decisions regarding timing, place, and mode of delivery should be taken with a multidisciplinary team including obstetricians, physicians, anesthetists, and intensivists experienced in the care of covid-19 in pregnancy. Ideally these decisions should take place in consultation with centers that have experience and expertise in all these specialties.