| Prone positioning |
For mechanically ventilated pregnant women with COVID‐19 and hypoxaemia despite optimising ventilation, consider prone positioning for more than 12 h a day (consensus recommendation). -
For pregnant and postpartum women with COVID‐19 and respiratory symptoms who are receiving any form of supplemental oxygen therapy and have not yet been intubated, consider prone positioning. When positioning a pregnant woman in prone, care should be taken to support the gravid uterus to reduce aorta‐caval compression. Women who are deteriorating should be considered for early endotracheal intubation and invasive mechanical ventilation. Birth of the baby should be considered when it may enhance maternal resuscitation or be beneficial to the fetus (consensus recommendation).
Current reports suggest prone ventilation in adult patients is effective in improving hypoxia associated with COVID‐19. This should be done in the context of a hospital guideline that includes suitable personal protective equipment for staff, and that minimises the risk of adverse events, e.g. accidental extubation. Proning of a pregnant woman should avoid abdominal compression and ensure a woman's hips and chest are supported. In the absence of specialised equipment, proning can be performed using pillows and blankets. Proning can be challenging in late gestation and delivery of the baby may be warranted.
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| Extracorporeal membrane oxygenation (ECMO) |
Consider referral to an ECMO centre for venovenous ECMO in mechanically ventilated pregnant women with COVID‐19 and refractory respiratory failure (despite optimising ventilation, including proning). Delivery of the baby prior to ECMO to enhance maternal resuscitation should be considered on a case‐by‐case basis (consensus recommendation).
Due to the resource‐intensive nature of ECMO and the need for experienced centres, healthcare workers and infrastructure, ECMO should only be considered in selected pregnant women with COVID‐19 and severe ARDS. The decision on whether to use ECMO should be taken in consultation with the woman's family, as well as obstetric and intensive care specialists. Key considerations include gestational age, fetal viability, fetal well‐being and the risks and benefits to mother and baby. Early referral to an ECMO centre is preferred. As pregnant and postpartum women may have haemostatic alterations, anticoagulation regimens may need to be modified appropriately.
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