COVID-19 Update #3: Treating the Pregnant Patient
/Prevention of COVID-19: More Updates on Vaccination
Vaccination is the #1 thing folks can do to protect themselves and their fetuses!
Since our last podcast, ACOG, SMFM, ASRM, ACNM, AABM (just to name a few) have all endorsed COVID-19 vaccination at any time for folks trying to conceive, who are pregnant, or postpartum and lactating!
SMFM has released consensus guidance for healthcare providers regarding vaccine counseling:
COVID and Pregnancy: What Options Are Available for Treatment?
We’re going to address the following major questions today:
Does patient merit inpatient admission?
If they can stay outpatient, does the patient qualify for any therapy?
If they need to be inpatient, when to start therapeutics and what options are available?
When is delivery indicated for maternal benefit?
Decision to Admit:
COVID can be broken into asymptomatic disease, then mild, moderate, severe, and critical disease:
Mild
Flu-like symptoms: fever, cough, myalgias
Anosmia
No dyspnea, shortness of breath, or abnormal chest imaging (if performed)
Moderate:
Symptomatic dyspnea/shortness of breath, but able to maintain SpO2 > 94% on room air
Evidence of pneumonia on imaging
Refractory fever (>39C) to acetaminophen
Severe:
Respiratory rate > 30
SpO2 < 94% on room air (so any O2 requirement!)
PaO2 / FiO2 < 300
More than 50% lung area involvement of disease on imaging
Critical:
Multiorgan failure or dysfunction, shock
Respiratory failure requiring high flow nasal cannula or mechanical ventilation
Patients with mild disease or no symptoms can be safely monitored outpatient, with a 10-day self quarantine from positive test or onset of symptoms in accordance with CDC guidelines.
Patients with moderate disease will often require hospitalization in pregnancy, owing to risk of progression. However, this is an individualized decision, and non-pregnant folks might more typically stay outpatient in this scenario.
If patients remain outpatient, SMFM recommends ongoing check-ins from patients to their prenatal care providers to assess symptoms and ensure there is no concern for disease progression.
Also recommend a follow up visit (either in-person or via telemedicine) at least once within 2 weeks of diagnosis.
Necessary and indicated medical care should not be avoided due to a positive COVID status!
Patients with severe or critical disease, obviously, will merit inpatient admission.
Patients with mild-moderate disease with other comorbidities may also be considered for hospitalization (i.e., patients with hypertension, diabetes, other maternal medical conditions), as these patients appear to be more prone to acute decompensation.
Inpatient Care: Protocols and Hospital Disposition
Vital signs and fetal monitoring as indicated when fetal intervention would be considered.
ICU level of care should be considered with:
Rapidly increasing oxygen needs to maintain SpO2 >95%
Hypotension (MAP < 65) despite some measure of fluid resuscitation.
Owing to risk of pulmonary edema, SMFM recommends an initial 500-1000cc bolus of crystalloid to assess response, and conservative fluid management unless clearly hypovolemic.
Need for mechanical ventilation or intubation -
Intubation is recommended if O2 requirements are >15L by NC or mask, >40-50L by high-flow NC, >60% FiO2 by Venturi mask, or altered mental status with inability to protect airway.
Need for other end-organ support (i.e., hemodialysis)
Prone positioning is possible in pregnancy!
Proning in COVID (and other causes of acute respiratory distress syndrome) is well-studied
It is hypothesized to decrease ventilation-perfusion mismatch by bringing more blood to the more open anterior lung fields (rather than the often atelectasis-affected lower posterior lung).
Padding and support devices may need to be used for appropriate support in pregnancy.
In non-intubated patients, lateral-decubitus or full-prone positioning is also permissible and can help improve oxygenation.
Thromboprophylaxis is generally recommended in at least hospitalized patients, given critical illness increases hypercoagulability risk further in pregnancy.
Prophylaxis is generally not recommended after discharge, unless other specific comorbidities exist.
SMFM offers use of a risk scale, the IMPROVE Risk Score, as well as deferring to clinical expertise to guide use of pharmacologic prophylaxis once discharged from the hospital.
Extracorporeal membrane oxygenation (ECMO)
Allows for oxygenation of the lungs (VV ecmo) and possibly combining with pumping action (VA ecmo) in patients with severe ARDS refractory to other methods of therapy.
It gets even more complicated than this, but that’s the basics!
ECMO is a significant intervention with its own set of morbidities and risks, and should be reserved for significant, severe cases of pregnancy where it may be helpful and delivery may not/cannot be considered at that present moment (i.e., previable or periviable gestation).
These conversations are often very individualized by institution, so we’ll hold off on further discussion from here!
Therapeutics and Indications
Outpatient:
Monoclonal antibody therapy (i.e., Regeneron)
FDA Emergency Use Authorization indicated for patients over age 12 who have mild-to-moderate COVID-19, weigh at least 40kg, and are at high risk of progression to severe disease or hospitalization. The criteria are:
BMI > 35
Chronic kidney disease
Diabetes
Immunosuppresive therapy
Data is limited on their use in pregnancy, but other monoclonal antibodies are generally well-tolerated with no fetal effects. Thus, they can be used in appropriate pregnant patients.
Inpatient:
Dexamethasone
Associated with decreased risk of mortality in those requiring mechanical ventilation
Also has small decrease in mortality for those requiring oxygen generally
(RECOVERY Trial)
Recommended dosing: 6mg IV or PO daily x 10 days.
NOT recommended in those who do not require oxygen
Dexamethasone does cross the placenta measurably: it is the alternative steroid to betamethasone for fetal lung maturity!
FLM dosing: 6mg IM q12h x 4 doses
Thus, it is appropriate to use in appropriate pregnant patients; FLM dosing should be given for the first 48h of therapy.
Remdesivir
Associated with decreased duration of disease in patients requiring oxygen therapy (ACTT-1 Trial)
Recommended if SpO2 < 94% on mechanical ventilation or ECMO
No fetal toxicity is known, and can be used on an emergency / compassionate use basis.
When to deliver the hospitalized patient:
SMFM recommends that in patients with refractory hypoxemia, delivery at/after 32 weeks is reasonable if it will allow for further care optimization given:
Low risk of neonatal mortality at 32 weeks (0.2%) and
Overall low risk of major morbidity (8.7% at 32 weeks).
This also logistically is often more appropriate - controlled delivery is certainly more preferable to chaos!
In those who are critically ill, decision for delivery is certainly individualized.
Mechanical ventilation alone is not an indication for delivery.
Proning, ECMO, and other ventilator methods should be considered especially under 30-32 weeks.