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Pregnant patients with severe COVID-19 need special treatment considerations, particularly with regard to oxygen and fluid levels, according to new recommendations published ahead of print on April 29 in Obstetrics & Gynecology.
Oxygen therapy via nasal cannula or facemask is the first treatment for hypoxemic pregnant patients with COVID-19 and should be started early, warn Luis D. Pacheco, MD, a maternal-fetal medicine expert in the Departments of Obstetrics/Gynecology and Anesthesiology at the University of Texas Medical Branch in Galveston, and colleagues.
They recommend starting oxygen when peripheral capillary oxygen saturation (SpO2) levels fall below 94% instead of the threshold for nonpregnant individuals (suggested at 92% and recommended at 90%) because pregnant patients need more oxygen and have increased partial pressure of oxygen.
Once oxygen is started, obstetricians should alert an anesthesiologist or other airway management expert in case intubation is necessary later.
High-Flow Nasal Cannula
Pacheco told Medscape Medical News the recommendations were developed on the basis of expert opinion gleaned from treating high-risk pregnancies. Most hospitals, including his, have seen few to no pregnant patients with severe COVID-19.
He said the most important recommendation may be introducing high-flow nasal cannula as the first option if the patient is not doing well on just oxygen therapy, explaining that many providers may be unfamiliar with that device.
“While that is well-known outside of pregnancy, in our opinion the same should apply to pregnant women,” he said.
In high-flow, oxygen is delivered at rates as high as 60 liters/minute, and air is heated and humidified. The authors outline flow parameters and steps for administration.
Positioning the patient on their abdomen — a technique referred to as “proning” — is widely encouraged as a potential way to help certain patients avoid or postpone mechanical ventilation and may be considered for pregnant patients at fewer than 20 weeks of gestation.
“Together with oxygen therapy, asking the patient to lay down in bed prone (awake self-prone position) appears to improve oxygenation (likely by anterior displacement of the mediastinum and improved posterior lung recruitment),” the authors explain.
Even Hotspots See Few Cases
Even in COVID-19 hotspots, such as Massachusetts, acute respiratory distress in pregnant patients with COVID-19 is infrequent, Sara Rae Easter, MD, a maternal-fetal expert at Brigham and Women’s Hospital in Boston told Medscape Medical News.
She said this article provides a quick, important summary for obstetricians and intensivists who may be seeing their first pregnant patients with COVID-19.
“Even the most seasoned internist could be asked to manage a pregnant patient and still have anxiety or lack of familiarity with that domain,” she said.
The guidance is particularly important because at many hospitals pregnant people who have medical complexities are traditionally likely to be transferred to specialists, but with COVID-19, there may not be time or available beds elsewhere.
“The guidance may provide some reassurance to those who are great at the medicine part and great at the ICU part but may get thrown off by the pregnancy piece,” she said.
She said one caution is that pregnant patients with severe COVID-19 may “look like they’re doing very well and then worsen out of nowhere.”
“Even though high-flow is appealing to avoid endotracheal intubation,” she said, “it’s important to be mindful you do need time to prepare to intubate pregnant patients and they will likely have a more challenging airway and have less oxygen reserves.”
More data on whether high-flow therapy increases the risk to healthcare providers is also needed, she said, noting that although endotracheal intubation is a high-risk procedure, it limits the time the provider is potentially exposed to the virus.
“It’s part of balancing what’s in the best interest of the patient with what will protect the safety and well-being of the healthcare provider,” she said.
Easter said the authors’ fluid management guidance may help assure providers that “keeping patients on the more dehydrated side of the spectrum is very important. The strategy that works well in the nonpregnant population should also be applied to pregnant patients,” she said, noting that “healthy lungs are dry lungs.”
The authors recommend avoiding maintenance fluids in pregnant patients with acute COVID-19 and a SpO2 lower than 94%.
One thing the authors do not address is preventing blood clots, Easter said.
“We all know that COVID patients are at a higher risk of developing blood clots or venous thromboembolism and we know that pregnant patients are also at risk of developing blood clots,” she said.
While guidelines around anticoagulation to try to prevent these events are emerging for the general COVID-19 population, she said, she looks forward to more guidance on recommendations for avoiding blood clots in this high-risk state of pregnancy.
The authors and Easter have disclosed no relevant financial relationships.
Obstet Gynecol. Published online April 29, 2020. Abstract
Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, The Cincinnati Enquirer, and the St. Cloud (Minn.) Times. She can be reached at @mfrellick.