Delivery for respiratory compromise among pregnant women with coronavirus disease 2019

Objective

Although rapid recourse to delivery after failed cardiopulmonary resuscitation has been shown to improve outcomes of pregnant patients experiencing cardiac arrest,^{1 , 2} it is not known whether delivery improves or compromises the outcome of patients with coronavirus disease 2019 (COVID-19) experiencing respiratory failure.^{3 , 4} This study aimed to evaluate the safety and utility of delivery of pregnant women with COVID-19 needing respiratory support.

Study Design

This is a retrospective observational study of pregnant women diagnosed with COVID-19 via polymerase chain reaction who developed severe disease (defined per previous publications³). A subset of these cases was previously presented but without details on the effect of delivery on the disease.⁵ The study was exempted by the institutional review board.

Results

Of 125 confirmed cases of COVID-19, 12 (9.6%) had severe disease (Table ). Among the 12 patients, the condition of 3 patients improved after receiving transient respiratory support in the hospital, and they were discharged home (1 subsequently returned in preterm labor and gave birth by cesarean delivery 2 weeks later). Of the remaining 9 patients who continued to need respiratory support, 7 (77.8%) had iatrogenic preterm deliveries (6 by cesarean delivery) for maternal respiratory distress (needing increasing levels of respiratory support without improved oxygen saturation), 1 had an early term delivery because of premature rupture of membranes, and 1, at 30 weeks’ gestation, was admitted to the intensive care unit with high-flow nasal cannula for 3 weeks.

Table.

Characteristics and outcomes of pregnant women with severe COVID-19

Patient number	1	2	3	4	5	6	7	8	9	10	11	12
Age (y)	44	33	34	28	37	32	34	25	32	24	30	29
BMI (kg/m2)	28.4	30.3	36.0	25.9	29.3	29.3	30.8	32.5	41.0	31.0	42.0	29.4
Medical history	None	None	Pregestational diabetes, hepatitis B	None	Gestational diabetes A2	None	Gestational diabetes A1	None	Chronic hypertension	None	None	None
Gestational age at initial symptom	294	334	353	310	285	315	372	330	260	346	260	253
Mode of delivery	Cesarean	Cesarean	Cesarean	Cesarean	Cesarean	Cesarean	Vaginal	Cesarean	—	Vaginal	—	—
Indication	Maternal respiratory distress	Maternal respiratory distress	Maternal respiratory distress	Maternal respiratory distress	Monochorionic diamniotic twins	Maternal respiratory distress	Early term PROM	Maternal respiratory distress	—	Maternal respiratory distress	—	—
Gestational age at delivery	314	353	362	324	314	316	372	344	—	351	—	—
Respiratory support	Nonrebreather	Simple nasal cannula	Mechanical ventilation	Nonrebreather	Simple nasal cannula	Simple nasal cannula	Simple nasal cannula	Simple nasal cannula	Simple nasal cannula	Simple nasal cannula	High-flow nasal cannula	Simple nasal cannula
ICU	No	No	Yes	No	No	No	No	No	No	No	Yes	No
LOS (d)	9	4	26	8	7	7	3	9	3	8	X	5
LOS after delivery (d)	7	4	26	5	4	4	3	8	—	5	—	—

BMI, body mass index; COVID-19, coronavirus disease 2019; ICU, intensive care unit; LOS, length of hospital stay; PROM, premature rupture of membranes; X, currently admitted for 15 days as of May 1, 2020.

Mclaren. Delivery for respiratory compromise among pregnant women with COVID-19. Am J Obstet Gynecol 2020.

Of the 8 patients delivering with maternal respiratory distress, 7 did not require intubation, and 1 was intubated for emergent cesarean delivery and remained on a ventilator for 19 days. Among the nonintubated, 4 had an improvement in oxygenation within 2 hours after delivery, 2 required less respiratory support, and 2 were taken completely off respiratory support. None of the other 3 patients required an increased level of respiratory support, and they were off of all support between 4 and 7 days after delivery.

Conclusion

Delivery did not worsen the respiratory status of women with persistent oxygen desaturation and the need for increasing respiratory support. Among women not needing a ventilator, the return to normal respiratory status after delivery occurred within hours to days. However, the 1 patient who was intubated intraoperatively took longer to recover. It is possible that delivery may be less salutary when damage to the lungs is sufficient to warrant intubation. This series suggests that maternal respiratory distress should not be a contraindication to delivery.

As noted in a recent Society for Maternal-Fetal Medicine and Society for Obstetric Anesthesia and Perinatology guideline, it is not known whether uterine decompression improves respiratory status; we are unable to shed light on that issue.⁴ Although we saw no harm, we cannot be certain that delivery per se caused the improvement we observed or whether a similar outcome could have been achieved with ongoing respiratory support (although 1 of 3 patients managed conservatively remained on respiratory support for 3 weeks). In summary, although more data on the effects of delivery are needed, we have shown in a small series that women with COVID-19 requiring respiratory support fared well when they underwent delivery.