Pregnancy

in the

Time of

COVID-19

Maternal-Fetal Medicine

KUSM-Wichita

I have no conflicts of interest to report.

Objectives

Pathogenesis

Case Presentation

Symptoms

Treatment

Management in Pregnancy

ID

Case Presentation

GP is a 36 y/o G4 P1021 GA 240 weeks that

tested + for COVID-19 5 days PTA

Transferred for worsening SOB x 2 days

with O2 sats in the 80s on 5L O2 per NC

VS: T 973, P 107 BP 112/56

PMHx: T2DM, previous C/S x1

Transferred to MICU for increasing distress

Pt desired C/S for Ob indications

Intubated about 4 hours after admission

ABGs 7.09/45/87/3.4/95%;base xs -15.9

Labs: Creatinine 0.6, lymphocytes 12.6%

CRP>1900, d-dimer 2020, AST 102,

glucose 378, HgbA1c 10.2%

Started on dexamethasone, therapeutic

heparin, insulin pump, bicarbonate,

pressors, broad-spectrum antibiotics

CXR: bilateral confluent opacities, R>L

Tube feedings

Continuous renal replacement therapy

Convalescent plasma x 2

Kept paralyzed/sedated in prone position

Tocilizumab

Remdesivir

Labile BPs

DKA resolved HD #4

Escaped delivery

D/Ced dialysis HD #9

Extubated HD #21

Discharged undelivered on HD #39

Pathogenesis

Pathogenesis

Pathogenesis

ACE-2 suspected receptor for COVID-19

ACE-2 receptors primarily in Type 2

alveolar cells

Found throughout aerodigestive tract

ACE-2 receptors attenuated in women

Inflammatory Response

Cytokine Storm

Defective immune response

Overproduction of pro-inflammatory cytokines

Damages lung infrastructure

Cytokine storm circulates to other organs

Multi-organ failure

Symptoms & Severities

Symptoms

Fever or chills

Cough

Fatigue

Shortness of breath or difficulty breathing

Symptoms

Headache

Sore throat

Muscle/body aches

New loss of taste or smell

Symptoms

Diarrhea

Nausea or voming

Congestion or runny nose

Testing

Antigen Testing

Point of care tests

Send to lab

What We Have at WMC

Abbott ID NOW COVID-19

Sensitivity: 91% [95% CI 0.76-0.97]

DiaSorin Molecular Simplexa COVID-19

Sensitivity: 100% [95% CI 0.98-1.00]

Am J Clin Pathol 2020. DOI:10.1093/ajcp/aqaa097

Cepheid Xpert Xpress SARS-CoV-2

Severity of Symptoms

China

Study*

Ob

Study

Mild

Severe

Critical

*International Journal of Surgery 77 (2020) 206-16.

81%

14%

5%

Am J Obstet Gynecol MFM 2020.

doi.org/10.1016/j.ajog.mf.2020.100118

86%

9.3%

4.7%

Incubation period up to 14 days

Median time of 4-5 days from exposure to

symptoms onset

Presymptomatic/Asymptomatic

Presymptomatic/Asymptomatic

Close Monitoring

Daily self-assessments

Telehealth an option

Mild Disease

Presence of symptoms:

• Cough

• Fever responsive to acetaminophen

• Myalgias

• Loss of taste or smell

• NONE of the following:

• Dyspnea/tachypnea

• Abnormal chest imaging

Mild Disease

• Consider inpatient management if

comorbidities are present:

• Uncontrolled hypertension

• Suboptimally controlled GDM/ or

pregestational diabetes

• Chronic renal/cardiopulmonary disease

• Immunosuppression

Stay away from other people/pets for 14 days

Avoid public transportation

Monitor symptoms

Keep in touch with your provider

Get rest & stay hydrated

Emergency Warning Signs

Trouble breathing

New confusion

Cyanosis

Inability to wake or stay awake

Persistent pain/pressure in chest

Preterm contractions, vaginal bleeding, or

decreased fetal movement

Call your provider’s office, 911 or medical

facility that you may (do) have COVID-19

before showing up & wear a mask

Supportive Care with Mild Disease

Conservative fluid management

O2 therapy to keep sats >94%

VTE prophylaxis?

Prone positioning

Consult Infectious Disease

Prone Positioning

Moderate Disease

Presence of symptoms with any of:

Fever despite acetaminophen

Dyspnea/tachypnea

Abnormal chest imaging

Abnormal ABGs

Unable to maintain O2 sats > 94%

Needs Hospitalization

Vital signs q 2-8 hours

Continuous pulse oximetry

Early warning signs:

Increased dyspnea or work at breathing

Inability to maintain O2 sats

Persistent or more frequent fevers

Worsening of myalgias

Treatment

Arterial Blood Gases in Pregnancy

Parameter Non-pregnant Pregnant 2nd & 3rd

adult trimester

pH 7.35-7.45 7.40-7.49

PaO2 (mmHg) 80-100 90-110

PCO2 (mmHg) 35-45 25-33

HCO3 (mEq/L) 21-30 16-22

Normal state in pregnancy is a compensated

respiratory alkalosis

Laboratory Evaluation

Lymphopenia

Leukocytosis

Elevated CRP, LDH, D-dimer

Elevated LFTs & creatinine may be

evidence of end-organ damage

Procalcitonin

Moderate to Severe Disease

Nasal cannula: maximum 15 L/min

Non-rebreather face mask: 15 L/min

High-flow nasal cannula: 60 L/min

You might want to make sure someone with

intubating skills is aware of the situation

Venturi face mask: FiO2 maximum of

60% oxygen delivery

Severe Disease

>50% lung involvement on imaging

RR > 30 bpm

O2 sats <93%

Ratio of PaO2/FiO2 <300

Severe Disease: Admission to ICU

Inability to maintain O2 sats >95% with

supplemental O2

New end-organ dysfunction

Intensivist/critical care team consultation

Critical Disease

Hypotension (MAP <65) despite adequate

fluid resuscitation

Multi-organ failure or dysfunction

Respiratory failure requiring mechanical

ventilation

Therapeutics

On June 15, 2020; the FDA revoked

the EUA for both drugs

Randomized, controlled open-labelled trial

in 176 hospitals in the UK

Dexamethasone 6 mg po or iv daily x 10 days

If pregnant or breastfeeding, received

methylprednisolone 40 mg po or

hydrocortisone 80 mg iv bid

Decreased mortality if intubated by about 1/3

& if only requiring O2, mortality decreased by

1/5

Corticosteroids

Convalescent Plasma Transfusion (CPT)

K Rajendran et al. J Med Virol.2020;1-9

27 total patients; 17 had ARDS & 7 on ECMO

CPT significantly reduced viral load &

increased level of neutralizing antibodies

ARDS resolved & off ventilation within 1 to

maximum of 35 days after CPT

Zero mortality

Can’t make definitive conclusion on optimal

doses & treatment time point for CPT

Remdesivir Phase III Trial Begins

for Moderate Disease

Open-label study

Remdesivir for 5 or 10 days v.

standard of care

5-day group: 65% more likely to have

clinical improvement at day 11

OR 1.65 [95% CI 1.09-2.48]

10-day group trended towards improvement

Remdesivir for Severe COVID-19

J. Grein et al. N Engl J Med 04/10/2020 DOI:10.1056/NEJM oa2007016

53 patients: received Remdesivir 200 mg iv

on day 1, followed by 100 mg iv qd x 9 days

At baseline, 30 pts. (57%) were on mechanical

ventilation and 4 (8%) on ECMO

Improvement in 36/53 patients (68%)

Mortality rate of 13% (7 patients)

Anticoagulation & COVID-19

Patients who are critically ill or on

mechanical ventilation should receive

thromboprophylaxis

Some advocate using CRP &/or D-dimer

to guide management

No clinical data to suggest that early,

full-dose anticoagulation is beneficial

What About the Fetus?

Fetal & tocodynamometer monitoring

should be used when fetal intervention,

including delivery, would be considered

based on GA, fetal/maternal status &

maternal preferences

Unknown if COVID-19 transmitted vertically

or via breast milk

AP testing for usual Ob indications

Delivery in the Critically Ill Patient

Should be individualized on maternal &

fetal status

Mechanical ventilation NOT an indication

for delivery

In the 3rd trimester, unclear whether

delivery provides an improvement in

ventilation

Delivery in the Asymptomatic/

Mildly Symptomatic Patient

+COVID-19 status not indication for delivery

Patient should wear mask

PPE needed for health care providers

Consider early epidural to prevent need for

intubation

Mode of delivery as per Ob indications

Delivery in the Asymptomatic/

Mildly Symptomatic Patient

37 0/7 weeks-38 6/7 weeks, expectant

management until 14 days after PCR test

positive or 7 days after symptoms

started & 3 days after resolution of

symptoms

Delivery at 39 weeks GA or after, delivery

may be considered to decrease risk of

worsening maternal status

Mother with COVID-19

CDC/WMC recommend that symptomatic

COVID + patients be separated from infant

Infant to be tested 24-48 hours post-delivery

After hand hygiene while wearing mask,

a non-infected support person may feed

expressed breastmilk to infant

Asymptomatic Mothers with + COVID-19

Option 1: separate rooms

Option 2: room-in together

6 ’ apart, ideally separated by curtain

Bathe infant ASAP to remove potential

virus from skin

Masked healthy support person caring for infant

Concluding Thoughts

As data collected, best practices will

continue to evolve

Unknown if COVID-19 transmitted vertically

or by breastmilk

Telemedicine when able

Consultation when appropriate

Questions?