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

Wong, Michael; Bharadwaj, Shobana; Lankford, Allison; Galey, Jessica L; Kodali, Bhavani Shankar

doi:10.1016/j.ijoa.2021.103236

Cited by 19 publications

(18 citation statements)

References 34 publications

(32 reference statements)

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“…Previous studies showed that obesity was a risk factor of intubation in pregnant women with COVID-19 [ 5 , 8 ] and that NIV but not HFNO use was not associated with a reduction in oxygenation failure in a large cohort of COVID-19 [ 26 ], probably because NIV was mainly used as a rescue therapy before intubation, as this was the case in our cohort. Awake prone positioning or prone positioning was performed in 26% of patients and before delivery in only 37% of them, although both of these postural maneuvers improve oxygenation in COVID-19 and non-COVID-19 patients [ 21 , 22 , 28 ], suggesting that physicians feared potential difficulties with fetal monitoring [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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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.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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“…Routine indications and contraindications should apply, although it may be appropriate to avoid the position in the immediate postoperative period after cesarean birth. In the third trimester, prone positioning may be more challenging technically, and the lateral decubitus position may be better tolerated76; the risks and benefits of delivery before prone positioning should be considered. When undertaken, ensure adequate padding above and below the gravid uterus to offload the uterus and avoid aortocaval compression 77.…”

Section: Managementmentioning

confidence: 99%

“…One patient developed uterine contractions while prone, which resolved when the woman was returned to the supine position. The authors reported that in some cases, maintaining continuous fetal monitoring while in the prone position required an early return to the supine position 76. This emphasizes the importance of multidisciplinary discussion to assess whether continuous fetal monitoring is needed if its application denies a pregnant woman the benefits of the prone position.…”

Section: Managementmentioning

confidence: 99%

Diagnosis and management of covid-19 in pregnancy

Nana

Hodson

Lucas

et al. 2022

BMJ

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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.

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“…In a case series of obstetric patients with severe COVID-19-related ARDS, 13 patients had prone positioning. None proning sessions were terminated owing to maternal hemodynamic or respiratory instability, or fetal intolerance [ 19 ].…”

Section: Discussionmentioning

confidence: 99%

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

James¹,

Guervilly

Lesouhaitier

et al. 2022

Crit Care

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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.

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

Cited by 19 publications

References 34 publications

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

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

Diagnosis and management of covid-19 in pregnancy

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

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