Welcome to the Society of Critical Care Medicine COVID-19 Resources. I will be discussing the care of critically ill pregnant COVID-19 patients. Briefly, we will discuss a general overview of critical illness and pregnancy. COVID-19 aside, fewer than 2% of women require ICU admission during pregnancy. ICU care in pregnancy does carry a high mortality. It is estimated to be between 3.4 to 14%. Pregnancy does worsen the clinical course of COVID-19 compared with non-pregnant individuals. Fortunately, greater than 90% of pregnant persons that are infected with COVID-19 recover without requiring hospitalization or delivery. COVID-19 in pregnancy, once pneumonia has set in, these women are at a higher risk of preterm delivery. A recent systematic review of 11,000 pregnant patients with COVID-19 demonstrated that of these admitted patients, 30% received oxygen via nasal cannula, 4% required admission to an ICU, 3% required invasive ventilation, 0.8% required ECMO, and 0.6% died secondary to COVID-19. Similar to the general population, pregnancy shares many of the same risk factors for severe illness. These include having an older age, a higher BMI, and preexisting comorbidities such as heart disease, lung disease, and diabetes. To review some of the general physiologic changes in pregnancy, secondary to the gravid uterus, there is an elevation of the diaphragm as well as reduced functional residual volumes in the lungs. Also, there is altered cellular immunity leading to increased susceptibility to viral infections such as COVID-19. Also, throughout pregnancy, there is an increased heart rate and secondarily, an increased cardiac output. There is an expanded blood volume leading to an anemia of dilution. Also, there is a reduced systemic vascular resistance leading to a lower blood pressure in the first and second trimester. Lastly, there is an increased respiratory rate leading to a respiratory alkalosis of pregnancy. If patients require more support than simple nasal cannula for oxygenation, high flow nasal cannula is the preferred method. If these patients require more support, noninvasive ventilation should be trialed prior to intubation and mechanical ventilation. Typical settings for noninvasive ventilation are recommended an inspiratory pressure of 12 to 15 and an expiratory pressure of 5 to 8. Parameters for ventilation, if these patients do require intubation, a goal PaO2 of greater than 70% to maintain fetal circulation and fetal oxygenation. A CO2 should be maintained between 30 and 32. This is the normal CO2 of pregnancy with the respiratory alkalosis that we talked about previously. Risk of the CO2 being lower than 30 include uterine blood flow being decreased. If the PaCO2 is higher than 40, fetal respiratory acidosis may occur. Studies have shown that there are no adverse outcomes for levels of the CO2 as high as If permissive hypercapnia is indicated for the management of ARDS. If high PEEP is indicated, make sure that you are closely monitoring the mother and the fetus. Both the preload and the cardiac output are decreased with higher levels of PEEP. If you have a patient that is refractory to mechanical ventilation and still hypoxic, you may consider ECMO. If our pregnant COVID-19 patients are requiring intubation, it is important that we sedate them properly. As far as analgesia goes, it is important to avoid the use of NSAIDs to prevent the premature closure of the ductus arteriosus. Opioids are generally acceptable medications for this purpose. Both fentanyl and morphine are both Category C in pregnancy. Generally safe, although they do carry the risks of some respiratory suppression as well as opioid withdrawal syndrome in neonates if these medications are used close to the time of delivery. As far as sedation, benzos are generally acceptable. Both midazolam and lorazepam are Category D. Propofol is a Category B drug in pregnancy and it has been shown to cause respiratory depression of the neonate. Prostatex has not really been studied in the critically ill obstetric patient. As far as neuromuscular blockade, this should generally be avoided. If this is indicated for vent desynchrony, cystatricurium is your Category B drug. It's going to be your preferable first-line agent. Vecuronium and pancuronium are both Category C. These can accumulate in the mother's body if she has any hepatic dysfunction that's going on. If these patients are coming in looking like they're in shock or having profound hypotension, vasopressors can be used, but they should be used with caution. These medications can restrict both uterine and fetal blood flow. Your initial management of hypotension should be using your IV fluids, placing the mother in the left lateral decubitus position to prevent the compression of that IVC and allow blood to return to the heart unimpeded. If a patient is refractorally hypotensive, not responding to fluids, norepinephrine is your first-line vasoactive agent of choice and is safe. Proning has been well studied in the management of ARDS and COVID-19. It is also safe and effective in pregnancy. If you're going to use this, it is important to use padding both above and below the gravid uterus to offload that area and to reduce the risk of compression of the aorta and the IVC. As you can see in this picture to the right, this bottom right image is showing these kind of towel rolls, both above and below the gravid uterus. If the patient is unable to be proned, you can also try the left lateral position as an alternative. Both COVID-19 and pregnancy increase your risk of venous thromboembolism. In these hospitalized and ICU-level patients, we are recommending prophylactic dose anticoagulation. Recommendations first-line agent is going to be your unfractionated heparin. This is preferred because it can be readily reversed for delivery, especially if these patients are past viability. Our recommendations are recommending 5,000 units Q12 in the first trimester, 7,500 units Q12 in the second trimester, and 10,000 units Q12 in the third trimester of pregnancy. A few general management considerations for these critically ill patients. It is important to be in close consultation with our obstetric colleagues for fetal monitoring, decision-making surrounding delivery, method of delivery, when and if it is appropriate to consider delivery to improve the respiratory status of the mother as well. At a minimum, we should be assessing fetal heart rates daily on these patients, assessing the umbilical artery weekly by Doppler, assessing fetal growth by ultrasound every two weeks. If a patient is more unstable and the fetus is at a viable gestational age, more frequent or continuous monitoring may be indicated. A few other considerations. Consider transferring the patient to a center that has maternal fetal medicine capabilities if you are not at one of these centers. Also consider speaking with ECMO staff at your facility or transfer to an ECMO center if a patient is not responding well to mechanical ventilation alone. As far as timing of delivery of these patients, each case should be evaluated on an individual basis with our obstetric colleagues. As a general kind of rule, between viability and 32 weeks, continued maternal support is really all that is indicated, supporting the mother. And then these next two categories, severe disease, which is defined as a respiratory frequency greater than 30 breaths per minute, less than 94% oxygen on room air, and lung infiltrates greater than 50% of the lung volume. Delivery may be recommended if gestational age greater than 32 weeks in the setting of worsening maternal status. Critical disease, which is defined as respiratory failure, intubation, septic shock, and multiple organ dysfunction. Again, no clear recommendations, but delivery may be indicated after consideration of both the mother and the fetus. As far as management of COVID-19 in these patients, pregnant women are eligible to receive corticosteroids per the guidelines at your facility. Steroids for lung maturation of the fetus should also be given per guidelines. Desivir has been used in these patients successfully, if they otherwise qualify. Plasma has been used successfully, and monoclonal antibodies are recommended in the appropriate outpatient setting. Ribavirin is a known teratogen and should be avoided in these patients. As far as postpartum care, these neonates should be isolated from other healthy infants and cared for under the usual infectious control precautions and protocols at your facility. In general, mothers with COVID-19 should not be separated from the infant if they are otherwise able to care for them. Mask wearing and hand hygiene are still recommended. In one study, which followed 82 infants of COVID-19 positive mothers, no infant was positive postnatally despite rooming with the mother. Also, breastfeeding should be encouraged, secondary to all of the maternal and fetal benefits that we're aware of. Breast washing should be performed, as well as hand hygiene and mask wearing once again. One study showed that 43 of 46 breast milk samples from different mothers were negative for COVID-19 by PCR. Here are a list of my references. Thank you so much. I hope you have found this informative and helpful in the care of your COVID-19 patients. Thank you all so much for the work that you're doing each and every day.

care of critically ill pregnant COVID-19 patients

pregnancy and COVID-19

preterm delivery risk in pregnant women with COVID-19

intensive care for pregnant patients with COVID-19

breastfeeding and COVID-19 precautions