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COVID-19 and Women’s Health

COVID-19 and Pregnancy: Maternal Mortality in the ICU

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BACKGROUND AND PURPOSE:

  • Blitz et al. (AJOG, 2020) sought to determine the rate of maternal death among pregnant and postpartum women with COVID-19 admitted to ICU

METHODS:

  • Case series
  • Setting
    • 10 ICUs in New York (March 1, 2020 to May 6, 2020)
  • Participants
    • Hospitalized pregnant women with a positive COVID-19 test
  • Study design
    • COVID-19 diagnosis (RT-PCR) | Universal COVID-19 testing labor and delivery began half way during the study period
    • Data collection (from electronic health record): Demographics | Comorbidities | Duration of illness before hospitalization | Laboratory and imaging results | ICU treatments | Clinical outcomes
  • Primary outcome
    • Maternal death
  • Secondary outcomes
    • Length of hospitalization and ICU stay
    • Frequency and duration of invasive mechanical ventilation
    • Frequency of vasopressor administration
    • Urgent or emergent delivery associated with acute respiratory decompensation
    • Discharge from the hospital

RESULTS:

  • Data from 462 pregnant women included
  • Severe or critical COVID-19: 15% (70 women)
    • Admitted to ICU: 19% (13 women)
      • Mortality: 15% (2 women)
      • Discharged: 85% (11 women)
  • ICU admissions demographics
    • Mean maternal age: 33.8±5.2 years
    • Mean gestational age at hospitalization: 33.3±5.3 weeks
    • Multiparous: 69%
    • Hispanic: 38%
  • Comorbidities associated with ICU admission
    • No comorbidities: 46%
    • Obesity: 38%
    • Pulmonary conditions (e.g. asthma and sleep apnea): 23%
  • Symptoms and laboratory findings on initial evaluation
    • Tachycardia | Tachypnea | Hypoxemia
  • Common lab findings
    • Lymphopenia
    • Elevated transaminases
    • Elevated inflammatory markers
  • Length of hospital stay
    • Median length of hospitalization: 13 days
    • Median length of ICU stay: 8 days
    • Duration of hospitalization before ICU admission: 2±2 days
    • Duration of hospital stay after ICU admission: 3±3 days

Therapy Outcomes

  • Invasive mechanical ventilation: 62% (8 cases)
    • Postpartum: 5
    • Pregnant: 2  
    • Median duration of therapy: 8 days
    • Vasopressors required: 88%
  • Anticoagulation
    • Prophylactic or therapeutic dose anticoagulation: 100%
    • Cases of VTE: 0%
  • Pharmaceuticals
    • Hydroxychloroquine: 85%
    • Antibiotics (coverage for community-acquired pneumonia): 92%
  • Enrolled in clinical trials
    • Remdesivir: 23%
    • Interleukin-6–receptor inhibitors: 38%
    • Convalescent plasma therapy: 15%

Case studies of mortality cases

  • Case 1
    • Long, protracted course in the ICU
    • Experienced fetal demise at a periviable gestational age
    • Multiple organ failure and required renal replacement therapy
    • Prepregnancy BMI of >40 kg/m2 and obstructive sleep apnea
  • Case 2
    • Experienced rapid clinical deterioration after delivery
    • Severe respiratory distress, multiple organ failure, cardiopulmonary arrest
    • Prepregancy BMI of <30 kg/m2 and no comorbidities

Note: Prone positioning used in Case 1 but not 2 due to rapid decline

Deliveries

  • 7 women delivered during hospitalization
  • Delivery method
    • Urgent or emergent cesarean deliveries in the setting of acute respiratory decompensation: 71% (5 deliveries)
    • Emergent cesarean delivery for cord prolapse during induction of labor for worsening respiratory symptoms: 1 delivery
    • Vaginal delivery: 1 delivery
  • Preterm births: 57% (4 births)

CONCLUSION:

  • Maternal death occurred in 15% of COVID-19 positive women in the ICU and among 25% on mechanical ventilation
  • Hispanic women made up the largest racial/ethnic group included in this study
  • Potential limitations
    • Small sample size due to relative rarity of pregnant, COVID-19 positive ICU admissions
    • Treatment regimens were not the same for all patients
  • The authors state

…pregnant and postpartum women with COVID-19 admitted to the ICUs are at risk for maternal death, which may occur even in the absence of substantial baseline comorbidities

Longitudinal population-based cohort studies may offer more insights into mechanisms determining which patients infected with the virus are at highest risk

Learn More – Primary Sources:

Maternal mortality among women with coronavirus disease 2019 admitted to the intensive care unit

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Related ObG Topics:

118 Pregnant Women with COVID-19: Treatments and Outcomes
COVID-19 Case Series: Pregnancy and Infant Outcomes
Universal Screening: What Percent of Women Admitted to L&D are Positive for SARS-CoV-2?

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