COVID-19 Infection in Obstetrical Patients Requiring Intensive Care: An Update

Women who are pregnant and who have COVID-19 infection have unique challenges from both a medical and non-medical perspective. In a post-pandemic society, there are new considerations for prenatal and postnatal care in addition to infection control measures, physiologic changes in the pregnancy, and fetal needs. Pregnant women were discovered to be at much higher risk for intensive care unit (ICU) admission, invasive ventilation, extracorporeal membrane oxygenation (ECMO), and death than non-pregnant women. Risk persisted even when age, race/ethnicity, and underlying medical conditions were taken into account. Additionally, preterm birth, stillbirth, and postpartum hemorrhage have all been linked to higher obstetrical problems when comorbidity with COVID-19 infection exists. When presenting at an age over 35, with obesity, chronic hypertension, chronic lung disease, gestational diabetes, and pre-eclampsia, obstetric patients are especially susceptible to complications. Therefore, it is recommended that serious COVID-19 obstetric patients be managed by a multidisciplinary team, with the team having a thorough understanding of how to manage the ongoing COIVD-19 and pre-existing disorders. For COVID-19-infected patients who are not pregnant, the target oxygen saturation is 92%. Aiming for a higher objective of 95% is advised by the Society for Maternal-Fetal Medicine (SMFM), and if this is not attained with supplementary oxygen or with growing demand, intensive care admission should be considered. High-flow nasal cannula (HFNC) is a viable therapy when adequate oxygenation cannot be attained by conventional oxygen support and indications for endotracheal intubation are not imminent. The critically ill obstetric patient population can often benefit from mechanical ventilation strategies used in non-pregnant people with some notable exceptions. While permissive hypercapnia may be employed in the situation of acute respiratory distress syndrome (ARDS), it is typically advised not to exceed 60 mmHg. This is in contrast to pregnancy-specific hypocapnia, which is preferred to minimize fetal academia and oxygen dissociation changes. The Food and Drug Administration (FDA) recently approved intravenous tocilizumab for the management of COVID-19 in hospitalized patients taking systemic corticosteroids and requiring mechanical ventilation, NIV, or supplementary oxygen. The NIH currently advises preventive dosage heparin in hospitalized patients who need mechanical ventilation, comparable to those on HFNC or NIV, for both pregnant and non-pregnant people (unless contraindicated). Gestational age, preterm risk, risk of a serious disease for the mother, and risk of an unsettling fetal state should be balanced against each other while fetus delivery is taken into account.