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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