Clinical Course of Severe and Critical COVID-19 in Hospitalized Pregnancies: A US Cohort Study

Am J Obstet Gynecol MFM. 2020 May 8;100134. doi: 10.1016/j.ajogmf.2020.100134. Online ahead of print.

Abstract

Background: The COVID-19 pandemic has had an impact on healthcare systems around the world with 3.0 million infected and 208,000 resultant mortalities as of this writing. Information regarding infection in pregnancy is still limited.

Objectives: To describe the clinical course of severe and critical infection in hospitalized pregnant women with positive laboratory testing for SARS-CoV2.

Study design: This is a cohort study of pregnant women with severe or critical COVID-19 infection hospitalized at 12 US institutions between March 5, 2020 and April 20, 2020. Severe infection was defined according to published criteria by patient reported dyspnea, respiratory rate > 30 per minute, blood oxygen saturation ≤ 93% on room air, partial pressure of arterial oxygen to fraction of inspired oxygen <300 and/or lung infiltrates >50% within 24 to 48 hours on chest imaging. Critical disease was defined by respiratory failure, septic shock, and/or multiple organ dysfunction or failure. Women were excluded if they had presumed COVID-19 infection but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported.

Results: Of 64 pregnant women hospitalized with COVID-19, 44 (69%) had severe and 20 (31%) critical disease. The following pre-existing comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease and the mean BMI was 34 kg/m2. Gestational age at symptom onset was at a mean 29 ±6 weeks and at hospital admission a mean of 30 ±6 weeks, on a median day of disease 7 since first symptoms. Eighty-one percent of women were treated with hydroxychloroquine; 9% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days for severe, 10.5 days for critical, p=0.01). For those who required it, intubation usually occurred around day 9, and peak respiratory support for women with severe disease occurred on day 8. In women with critical disease, prone positioning was performed in 20% of cases, the rate of ARDS was 70%, and re-intubation was necessary in 20%. There was one case of maternal cardiac arrest, but no cases of cardiomyopathy and no maternal deaths. Thirty-two (50%) women in this cohort delivered during their COVID-19 hospitalization (34% of severe and 85% of critical women). Eighty-eight percent (15/17) of pregnant women with critical COVID-19 who delivered during their disease course were delivered preterm, 94% of them via cesarean; in all, 75% (15/20) of critically ill women delivered preterm. There were no stillbirths or neonatal deaths, or cases of vertical transmission.

Conclusion: In hospitalized pregnant women with severe or critical COVID-19 infection, admission typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 severe versus 12 critical). Critically ill women had a high rate of ARDS, and there was one case of cardiac arrest, but there were no cases of cardiomyopathy, or maternal mortality. Hospitalization for severe or critical COVID-19 infection resulted in delivery during the course of infection in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.

Keywords: COVID-19; SARs-CoV2; coronavirus; pregnancy.