Among pregnant or postpartum women admitted to the intensive care unit (ICU) with severe COVID-19 pneumonitis, those considered critical (ie, receiving or close to requiring invasive positive pressure ventilation [IPPV]) generally deteriorated on the day of delivery, took a longer time to recover, and experienced worse maternal outcomes, according to study findings published in The Lancet Respiratory Medicine.
Unresolved controversies related to severe COVID-19 pneumonitis in pregnancy include the optimum timing of delivery and whether delivery improves or worsens maternal outcomes. Researchers therefore sought to evaluate daily clinical data on pregnant and postpartum women who were admitted to the ICU with COVID-19, with particular attention paid to the days prior to and following delivery.
The OB-COVICU cohort study, a nationwide, multicenter, prospective and retrospective study conducted in Israel, evaluated all pregnant women who were admitted to an Israeli ICU with severe COVID-19 pneumonitis from the 13th week of gestation to the first week postpartum. All maternal and neonatal outcomes were assessed, along with longitudinal clinical and laboratory ICU data.
The primary overall outcome was maternal outcome — that is, the worst of the following: (1) no IPPV use; (2) use of IPPV; (3) use of extracorporeal membrane oxygenation (ECMO); or (4) death. The primary longitudinal outcome was Sequential Organ Failure Assessment (SOFA) score. The secondary longitudinal outcome was the novel PORCH (positive end-expiratory pressure [PEEP], oxygenation, respiratory support, chest x-ray, hemodynamic support) score.
All of the participants were classified into 1 of 4 groups: (1) no-delivery group: pregnant at admission and no delivery during ICU stay; (2) postpartum group: ICU admission at least 1 day after delivery; (3) delivery-critical group: pregnant at ICU admission and receiving or at high risk for receiving IPPV at the time of delivery; and (4) delivery-non-critical group: pregnant at ICU admission and not critically ill at the time of delivery.
Between February 1, 2020, and January 31, 2022, a total of 84 women were evaluated, with 34 patients in the no-delivery group, 4 in the postpartum group, 32 in the delivery-critical group, and 14 in the delivery-non-critical group.
Results of the study showed that the delivery-critical and the postpartum groups experienced worse outcomes compared with the other groups. Overall, 81% (26 of 32) of those in the delivery-critical group and 100% (4 of 4) of those in the postpartum group required IPPV. Additionally, 38% (12 of 32) of those in the delivery-critical group and 75% (3 of 4) of those in the postpartum group required ECMO. There was 1 death reported in the delivery-critical group and 2 deaths reported in the postpartum group.
Outcomes in the no-delivery group and the delivery-non-critical group were far better than the outcomes in the other 2 groups. Overall, 18% (6 of 34) of those in the no-delivery group and 14% (2 of 14) of those in the delivery-non-critical group required IPPV. No patients in either the no-delivery group or the delivery-non-critical group required ECMO or died.
Measures highly predictive (P <.0001) of adverse maternal outcomes included: oxygen saturation (SpO2); SpO2 to fraction of inspired oxygen (FiO2) ratio (S/F ratio); partial pressure of arterial oxygen to FiO2 ratio (P/F ratio); ROX index (S/F ratio divided by respiratory rate); and SOFA and PORCH scores.
Patients in the delivery-critical group deteriorated on the day of delivery, continued to deteriorate throughout their ICU stay, and took a longer time to recover (ICU duration, log-rank Mantel-cox P <.0001). In contrast, those in the delivery-non-critical group improved rapidly following delivery. The day of delivery was a significant covariate for PORCH score (P <.0001), but was not significant for SOFA score (P =.09).
Study limitations include its lack of randomization and lack of a control group; the prospective collection of data for some patients when most other data were collected retrospectively; and the use of potentially unfounded assumptions (based on unique circumstances within the study cohort) in the development of study conclusions.
“Interventional delivery should be considered for maternal indications before patients deteriorate and require mechanical ventilation,” study authors concluded. Additionally, given postpartum participants’ higher illness severity upon ICU admission and high mortality rate “[W]e advocate a reassessment of ICU admission criteria for postpartum patients with COVID-19 pneumonitis and the provision of additional vigilance if they continue to be managed in a non-ICU setting,” said study authors.
Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Fatnic E, Blanco NL, Cobiletchi R, et al; OB-COVICU study group. Outcome predictors and patient progress following delivery in pregnant and postpartum patients with severe COVID-19 pneumonitis in intensive care units in Israel (OB-COVICU): a nationwide cohort study. Lancet Respir Med. Published online February 3, 2023. doi:10.1016/S2213-2600(22)00491-X