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Mechanical ventilation, prone positioning, and delivery in pregnant patients with severe COVID-19

In February, practitioners from the University of Maryland Department of Anesthesiology published a study on the care and outcomes of 17 pregnant COVID-19 patients who required mechanical ventilation. The full manuscript, written by Michael Wong, Shobana Bharadwaj, Allison Lankford, Jessica Galey, and Bhavani Kodali, is available on the Journal of Obstetric Anesthesia website. Here we summarize their findings.

In February, practitioners from the University of Maryland Department of Anesthesiology published a study on the care and outcomes of 17 pregnant COVID-19 patients who required mechanical ventilation. The full manuscript, written by Michael Wong, Shobana Bharadwaj, Allison Lankford, Jessica Galey, and Bhavani Kodali, is available on the Journal of Obstetric Anesthesia website. Here we summarize their findings.

Due to the physiological changes associated with pregnancy, pregnant patients are particularly vulnerable to the effects of COVID-19. Factors like increased oxygen consumption and altered immunity make this population of particular interest when considering the effects of COVID-19, but few randomized controlled trials have been done to inform optimal care for these patients.

While prone positioning is recommended for the general population as a rescue therapy for acute respiratory distress syndrome (ARDS) and severe COVID-19, the effects of prone positioning have not been assessed among pregnant COVID-19 patients. Further, the effects of fetal delivery among pregnant patients with ARDS is controversial, with past studies yielding different results. The effect of fetal delivery among COVID-19 patients has not been assessed.

Wong et al. retrospectively assessed the effects of both prone positioning and fetal delivery in a cohort of pregnant patients at their hospital. They came away with four important conclusions:

  • Maternal and fetal survival was favorable after severe COVID-19
  • Prone positioning was not only feasible but well tolerated
  • The effect of prone positioning on maternal ventilation and oxygenation was not clear
  • Similarly, the effect of fetal delivery on maternal ventilation and oxygenation was not clear

Of their patients, none were repositioned (returned to a supine position) for worsening ventilation, gas exchange, hemodynamic instability, or fetal intolerance, suggesting that prone positioning could be a useful approach in pregnant patients with COVID-19. In further studies in a larger patient pool, traditional statistical tests would be possible to provide more conclusive evidence to support or contradict the use of prone positioning in this population.

While the sample size in Wong et al.’s study was also too small to formally evaluate the effects of fetal delivery, they did not find robust evidence that would support a maternal benefit of delivery. After tracheal intubation or airway management, three patients in their cohort required an emergency caesarian section in the ICU due to fetal heart rate or maternal hypoxemia. Wong et al. note point out an additional point for consideration based on these outcomes: airway management preparation can be precarious in these patients and should include contingency planning for emergent delivery.

In summary, Wong et al. provided useful evidence that contributes to the current understanding of complications, treatment, and outcomes among pregnant COVID-19 patients. They note that inclusion of pregnant patients in future preventative and interventional trials will be important for improving COVID-19 management.

For further reading, find Wong et al.’s complete manuscript in the Journal of Obstetric Anesthesia.

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