[Pregnant women with COVID-19 ARDS on the intensive care unit].

Die Schwangere mit COVID-19-ARDS auf der Intensivstation.

Publisher: Springer Medizin Country of Publication: Germany NLM ID: 9918384886806676 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 2731-6866 (Electronic) Linking ISSN: 27316858 NLM ISO Abbreviation: Anaesthesiologie Subsets: MEDLINE

Original Publication: [Heidelberg, Germany] : Springer Medizin, [2022]-

COVID-19*/therapy ; COVID-19*/epidemiology ; COVID-19*/complications ; Pregnancy Complications, Infectious*/therapy ; Pregnancy Complications, Infectious*/virology ; Extracorporeal Membrane Oxygenation*/methods ; Intensive Care Units* ; Respiratory Distress Syndrome*/therapy ; Respiratory Distress Syndrome*/virology; Humans ; Female ; Pregnancy ; Adult ; Infant, Newborn ; Critical Care/methods ; Cesarean Section ; Germany/epidemiology ; Cohort Studies ; Pregnancy Outcome/epidemiology

Background: Pregnant women with coronavirus disease 2019 (COVID-19) are at increased risk of severe disease progression. Comorbidities, such as chronic arterial hypertension, diabetes mellitus, advanced maternal age and high body mass index, may predispose to severe disease. The management of pregnant COVID-19 patients on the intensive care unit (ICU) is challenging and requires careful consideration of maternal, fetal and ethical issues.
Objective: Description and discussion of intensive care treatment strategies and perinatal anesthesiological management in patients with COVID-19 acute respiratory distress syndrome (CARDS).
Material and Methods: We analyzed the demographic data, maternal medical history, clinical intensive care management, complications, indications and management of extracorporeal membrane oxygenation (ECMO) and infant survival of all pregnant patients treated for severe CARDS in the anesthesiological ICU of a German university hospital between March and November 2021.
Results: The cohort included 9 patients with a mean age of 30.3 years (range 26-40 years). The gestational age ranged from 21 + 3 weeks to 37 + 2 weeks. None of the patients had been vaccinated against SARS-CoV‑2. Of the nine patients seven were immigrants and communication was hampered by inadequate Central European language skills. Of the patients five had a P a O 2 /F i O 2 index < 150 mm Hg despite escalated invasive ventilation (F i O 2 > 0.9 and a positive end-expiratory pressure [PEEP] of 14 mbar) and were therefore treated with repeated prolonged prone positioning maneuvers (5-14 prone positions for 16 h each, a total of 47 prone positioning treatments) and 2 required treatment with inhaled nitric oxide and venovenous ECMO. The most common complications were bacterial superinfection of the lungs, urinary tract infection and delirium. All the women and five neonates survived. All newborns were delivered by cesarean section, two patients were discharged home with an intact pregnancy and two intrauterine fetal deaths were observed. None of the newborns tested positive for SARS-CoV‑2 at birth.
Conclusion: High survival rates are possible in pregnant patients with CARDS. The peripartum management of pregnant women with CARDS requires close interdisciplinary collaboration and should prioritize maternal survival in early pregnancy. In our experience, prolonged prone positioning, an essential evidence-based cornerstone in the treatment of ARDS, can also be safely used in advanced stages of pregnancy. Inhaled nitric oxide (iNO) and ECMO should be considered as life-saving treatment options for carefully selected patients. For cesarean section, neuraxial anesthesia can be safely performed in patients with mild CARDS if well planned but the therapeutic anticoagulation recommended for COVID-19 may increase the risk of bleeding complications, making general anesthesia a more viable alternative, especially in severe disease.
(© 2024. The Author(s).)

RKI (2023) Coronavirus SARS-CoV‑2. www.rki.de /DE/Content/InfAZ/N/Neuartiges_Coronavirus/nCoV_node.html. Zugegriffen: 24. Okt. 2023.
Madjunkov M, Dviri M, Librach C (2020) A comprehensive review of the impact of COVID-19 on human reproductive biology, assisted reproduction care and pregnancy: a Canadian perspective. J Ovarian Res 13:140. (PMID: 33246480769459010.1186/s13048-020-00737-1)
DeBolt CA, Bianco A, Limaye MA et al (2021) Pregnant women with severe or critical coronavirus disease 2019 have increased composite morbidity compared with nonpregnant matched controls. Am J Obstet Gynecol 224:510.e1–510.e12. (PMID: 3322129210.1016/j.ajog.2020.11.022)
Allotey J, Stallings E, Bonet M et al (2020) Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ 370:m3320. (PMID: 3287357510.1136/bmj.m3320)
Larson SB, Watson SN, Eberlein M, Simmons JS, Doerschug KC, Leslie KK (2021) Survival of Pregnant Coronavirus Patient on Extracorporeal Membrane Oxygenation. Ann Thorac Surg 111:e151–e152. (PMID: 3303936110.1016/j.athoracsur.2020.09.004)
Juan J, Gil MM, Rong Z, Zhang Y, Yang H, Poon LC (2020) Effect of coronavirus disease 2019 (COVID-19) on maternal, perinatal and neonatal outcome: systematic review. Ultrasound Obstet Gynecol 56:15–27. (PMID: 32430957727674210.1002/uog.22088)
Wei SQ, Bilodeau-Bertrand M, Liu S, Auger N (2021) The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis. CMAJ 193:E540–E548. (PMID: 33741725808455510.1503/cmaj.202604)
Perico L, Benigni A, Casiraghi F, Ng LFP, Renia L, Remuzzi G (2021) Immunity, endothelial injury and complement-induced coagulopathy in COVID-19. Nat Rev Nephrol 17:46–64. (PMID: 3307791710.1038/s41581-020-00357-4)
Köstenberger M, Hasibeder W, Dankl D et al (2022) Update SARS-CoV-2 Behandlungsempfehlungen für die Intensivmedizin. Anästhesie Nachr 4:73–82. https://doi.org/10.1007/s44179-022-00019-9.
- (2020) Society for Maternal-Fetal Medicine and Society for Obstetric Anesthesia and Perinatology. Labor and delivery COVID-19 considerations.
Zöllkau J, Hagenbeck C, Hecher K et al (2022) Empfehlungen zu SARS-CoV-2/COVID-19 in Schwangerschaft, Geburt und Wochenbett – Update November 2021 (Langfassung). Z Geburtshilfe Neonatol 226:e1–e35. (PMID: 3491833410.1055/a-1688-9398)
Oxford-Horrey C, Savage M, Prabhu M et al (2020) Putting It All Together: Clinical Considerations in the Care of Critically Ill Obstetric Patients with COVID-19. Am J Perinatol 37:1044–1051. (PMID: 32575140741619810.1055/s-0040-1713121)
Husby A, Wohlfahrt J, Melbye M (2023) Gestational age at birth and cognitive outcomes in adolescence: population based full sibling cohort study. BMJ 380:e72779. (PMID: 36653028984668010.1136/bmj-2022-072779)
Singer D (2006) Die Langzeitprognose von Frühgeborenen: Was sich hinter den Statistiken verbirgt. Z Geburtshilfe Neonatol 210:50–59. (PMID: 1656593910.1055/s-2006-931552)
Berger R, Abele H, Bahlmann F et al (2023) Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry Number 015/025, September 2022)—Part 1 with Recommendations on the Epidemiology, Etiology, Prediction, Primary and Secondary Prevention of Preterm Birth. Geburtshilfe Frauenheilkd 83:547–568. (PMID: 371525441015971810.1055/a-2044-0203)
Vogel JP, Chawanpaiboon S, Moller A‑B, Watananirun K, Bonet M, Lumbiganon P (2018) The global epidemiology of preterm birth. Best Pract Res Clin Obstet Gynaecol 52:3–12. (PMID: 2977986310.1016/j.bpobgyn.2018.04.003)
Goedicke-Fritz S, Härtel C, Krasteva-Christ G, Kopp MV, Meyer S, Zemlin M (2017) Preterm Birth Affects the Risk of Developing Immune-Mediated Diseases. Front Immunol 8:1266. (PMID: 29062316564088710.3389/fimmu.2017.01266)
Vouga M, Favre G, Martinez-Perez O et al (2021) Maternal outcomes and risk factors for COVID-19 severity among pregnant women. Sci Rep 11:13898. (PMID: 34230507826073910.1038/s41598-021-92357-y)
Smith ER, Oakley E, Grandner GW et al (2023) Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: a sequential, prospective meta-analysis. Am J Obstet Gynecol 228:161–177. (PMID: 36027953939856110.1016/j.ajog.2022.08.038)
Panchaud A, Favre G, Pomar L, Vouga M, Aebi-Popp K, Baud D (2020) An international registry for emergent pathogens and pregnancy. Lancet 395:1483–1484. (PMID: 32353329718593910.1016/S0140-6736(20)30981-8)
Papageorghiou AT, Deruelle P, Gunier RB et al (2021) Preeclampsia and COVID-19: results from the INTERCOVID prospective longitudinal study. Am J Obstet Gynecol. https://doi.org/10.1016/j.ajog.2021.05.014. (PMID: 10.1016/j.ajog.2021.05.014349421548686449)
Galang RR, Newton SM, Woodworth KR et al (2021) Risk Factors for Illness Severity Among Pregnant Women With Confirmed Severe Acute Respiratory Syndrome Coronavirus 2 Infection-Surveillance for Emerging Threats to Mothers and Babies Network, 22 State, Local, and Territorial Health Departments, 29 March 2020–5 March 2021. Clin Infect Dis 73:S17–S23. (PMID: 3402133210.1093/cid/ciab432)
Goßner L, Siegert M (2023) COVID-19-Erkrankungen und Impfungen gegen SARS-CoV‑2 bei Personen mit und Personen ohne Migrationserfahrung – Ergebnisse aus der RKI-SOEP-2 Studie. Institut für Arbeitsmarkt- und Berufsforschung.
Villar J, Ariff S, Gunier RB et al (2021) Maternal and Neonatal Morbidity and Mortality Among Pregnant Women With and Without COVID-19 Infection: The INTERCOVID Multinational Cohort Study. JAMA Pediatr 175:817–826. (PMID: 3388574010.1001/jamapediatrics.2021.1050)
Mackin DW, Walker SP (2021) The historical aspects of vaccination in pregnancy. Best Pract Res Clin Obstet Gynaecol 76:13–22. (PMID: 3316842810.1016/j.bpobgyn.2020.09.005)
Zamparini J, Murray L, Saggers RT, Wise AJ, Lombaard H (2021) Considerations for COVID-19 vaccination in pregnancy. S Afr Med J 111:544–549. (PMID: 34382563)
Dagan N, Barda N, Biron-Shental T et al (2021) Effectiveness of the BNT162b2 mRNA COVID-19 vaccine in pregnancy. Nat Med 27:1693–1695. (PMID: 3449385910.1038/s41591-021-01490-8)
Ständige Impfkommission (2021) Beschluss der STIKO zur 10. Aktualisierung der COVID-19-Impfempfehlung. Robert Koch-Institut.
Gray KJ, Bordt EA, Atyeo C et al (2021) Coronavirus disease 2019 vaccine response in pregnant and lactating women: a cohort study. Am J Obstet Gynecol 225:303.e1–303.e17. (PMID: 3377569210.1016/j.ajog.2021.03.023)
Fell DB, Dimanlig-Cruz S, Regan AK et al (2022) Risk of preterm birth, small for gestational age at birth, and stillbirth after covid-19 vaccination during pregnancy: population based retrospective cohort study. BMJ 378:e71416. (PMID: 3597773710.1136/bmj-2022-071416)
Bos D, Guberina N, Zensen S, Opitz M, Forsting M, Wetter A (2023) Radiation Exposure in Computed Tomography. Dtsch Ärztebl Int 120:135–141. (PMID: 3663344910198168)
Loose R, Wucherer M (2017) Bildgebung in der Schwangerschaft. Radiopraxis 10:131–138. (PMID: 10.1055/s-0043-103146)
American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice (2016). Committee Opinion No. 656: Guidelines for Diagnostic Imaging During Pregnancy and Lactation. Obstet Gynecol 127(2):e75–80. https://doi.org/10.1097/AOG.0000000000001316.
Fröhlich JM, Kubik-Huch RA (2013) Röntgen‑, MR- oder Ultraschallkontrastmittel während der Schwangerschaft oder Stillzeit: Was ist zu beachten? Fortschr Geb Rontgenstr Nuklearmed 185:13–25.
Obed M, Gabriel MM, Dumann E, Vollmer Barbosa C, Weißenborn K, Schmidt BMW (2022) Risk of acute kidney injury after contrast-enhanced computerized tomography: a systematic review and meta-analysis of 21 propensity score–matched cohort studies. Eur Radiol 32:8432–8442. (PMID: 35727320970546910.1007/s00330-022-08916-y)
Oster ME, Riehle-Colarusso T, Alverson CJ, Correa A (2011) Associations between maternal fever and influenza and congenital heart defects. J Pediatr 158:990–995. (PMID: 2125650910.1016/j.jpeds.2010.11.058)
Guérin C, Reignier J, Richard J‑C et al (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368:2159–2168. (PMID: 2368830210.1056/NEJMoa1214103)
Tolcher MC, McKinney JR, Eppes CS et al (2020) Prone Positioning for Pregnant Women With Hypoxemia Due to Coronavirus Disease 2019 (COVID-19). Obstet Gynecol Clin North Am 136:259–261.
Bansbach J, Wenz J, Kaufmann K, Heinrich S, Kalbhenn J (2022) Sevoflurane in combination with esketamine is an effective sedation regimen in COVID-19 patients enabling assisted spontaneous breathing even during prone positioning. Anaesthesiol Intensive Ther 54:23–29. (PMID: 353591381015649210.5114/ait.2022.113950)
Gebistorf F, Karam O, Wetterslev J, Afshari A (2016) Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults. Cochrane Database Syst Rev 2016:CD2787. (PMID: 273477736464789)
Safaee Fakhr B, Wiegand SB, Pinciroli R et al (2020) High Concentrations of Nitric Oxide Inhalation Therapy in Pregnant Patients With Severe Coronavirus Disease 2019 (COVID-19). Obstet Gynecol Clin North Am 136:1109–1113.
Elliot CA, Stewart P, Webster VJ et al (2005) The use of iloprost in early pregnancy in patients with pulmonary arterial hypertension. Eur Respir J 26:168–173. (PMID: 1599440410.1183/09031936.05.00128504)
Horng M, Mohammad I, Smith ZR, Awdish RL, Cajigas HR (2016) Inhaled Iloprost for Chronic Thromboembolic Pulmonary Hypertension (CTEPH) During Pregnancy: A Case Report. Pharmacotherapy 36:e142–e147. (PMID: 2734107410.1002/phar.1793)
Ngatchou W, Ramadan ASE, van Nooten G, Antoine M (2012) Left tilt position for easy extracorporeal membrane oxygenation cannula insertion in late pregnancy patients. Interact CardioVasc Thorac Surg 15:285–287. (PMID: 22527087339773710.1093/icvts/ivs142)
Agerstrand C, Abrams D, Biscotti M et al (2016) Extracorporeal Membrane Oxygenation for Cardiopulmonary Failure During Pregnancy and Postpartum. Ann Thorac Surg 102:774–779. (PMID: 2715415810.1016/j.athoracsur.2016.03.005)
Kalbhenn J, Glonnegger H, Wilke M, Bansbach J, Zieger B (2021) Hypercoagulopathy, acquired coagulation disorders and anticoagulation before, during and after extracorporeal membrane oxygenation in COVID-19: a case series. Perfusion 36:592–602. (PMID: 3371973810.1177/02676591211001791)
El Banayosy AM, El Banayosy A, Smith JG et al (2023) Extracorporeal life support in pregnant and postpartum women with COVID-19-related acute respiratory distress syndrome. Int J Artif Organs 46:289–294. (PMID: 370516611009991410.1177/03913988231168431)
Clemenza S, Zullino S, Vacca C et al (2022) Perinatal outcomes of pregnant women with severe COVID-19 requiring extracorporeal membrane oxygenation (ECMO): a case series and literature review. Arch Gynecol Obstet 305:1135–1142. (PMID: 35262778890527510.1007/s00404-022-06479-3)
Webster CM, Smith KA, Manuck TA (2020) Extracorporeal membrane oxygenation in pregnant and postpartum women: a ten-year case series. Am J Obstet Gynecol MFM 2:100108. (PMID: 32835205736243310.1016/j.ajogmf.2020.100108)
Byrne JJ, Shamshirsaz AA, Cahill AG et al (2023) Outcomes Following Extracorporeal Membrane Oxygenation for Severe COVID-19 in Pregnancy or Post Partum. JAMA Netw Open 6:e2314678. (PMID: 372130991020388710.1001/jamanetworkopen.2023.14678)
Ranieri VM, Rubenfeld GD, Thompson BT et al (2012) Acute respiratory distress syndrome: the Berlin Definition. JAMA 307:2526–2533. (PMID: 22797452)
Campbell LA, Klocke RA (2001) Implications for the pregnant patient. Am J Respir Crit Care Med 163:1051–1054. (PMID: 1131663310.1164/ajrccm.163.5.16353)
(2019) 64 Anästhesie bei Schwangeren und in der Geburtshilfe (II). In: Striebel HW (Hrsg) Die Anästhesie. Thieme, Stuttgart.
Zöllkau J, Hagenbeck C, Hecher K et al (2020) Aktualisierte Empfehlungen zu SARS-CoV-2/COVID-19 und Schwangerschaft, Geburt und Wochenbett. Z Geburtshilfe Neonatol 224:217–222. (PMID: 32838449751636710.1055/a-1199-6404)
Poon LC, Yang H, Lee JCS et al (2020) ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals. Ultrasound Obstet Gynecol 55:700–708. (PMID: 32160345722822910.1002/uog.22013)
Bremerich DH, Greve S (2021) Die neue S1-Leitlinie „Geburtshilfliche Analgesie und Anästhesie“ – Vorstellung und Kommentar. Anaesthesist 70:229–236. (PMID: 3346437410.1007/s00101-020-00910-7)
Bernstein K, Landau R (2021) Management of maternal COVID-19: considerations for anesthesiologists. Curr Opin Anaesthesiol 34:246–253. (PMID: 3386745810.1097/ACO.0000000000001001)

Keywords: ARDS; COVID-19; ECMO; Pregnancy; Prone positioning
Local Abstract: [Publisher, German] HINTERGRUND: Schwangere mit einer SARS-CoV-2-Infektion (COVID-19) haben ein erhöhtes Risiko für einen schweren Verlauf der COVID-19. Die medizinische und ethische Abwägung maternaler und fetaler Risiken und die Priorisierung von Therapieoptionen stellen eine große Herausforderung auf der Intensivstation dar. Eine enge interdisziplinäre Abstimmung ist unabdingbar. [Publisher, German] Beschreibung und Diskussion intensivmedizinischer Behandlungsstrategien und des perinatalen anästhesiologischen Managements bei Patientinnen mit COVID-19-ARDS (CARDS). [Publisher, German] Analyse von demografischen Daten, Anamnese, klinischem Management, Komplikationen, Indikationen und Management der extrakorporalen Membranoxygenierung (ECMO) sowie des kindlichen Überlebens aller schwangeren Patientinnen, die zwischen März und November 2021 auf der anästhesiologischen Intensivstation eines deutschen Universitätsklinikums wegen eines schweren CARDS behandelt wurden. [Publisher, German] Kohorte von 9 konsekutiven Patientinnen mit einem Durchschnittsalter von 30,3 Jahren (Min–Max: 26 bis 40 Jahre) und einem Schwangerschaftsalter von 21 + 3 bis 37 + 2 Wochen. Keine der Patientinnen war gegen SARS-CoV‑2 geimpft. Zwei Patientinnen mussten mit inhalativem Stickstoffmonoxid und venovenöser ECMO behandelt werden. Alle Frauen und 5 Neugeborene haben überlebt. Zwei Patientinnen wurden mit intakter Schwangerschaft nach Hause entlassen. Alle Kinder wurden durch einen Kaiserschnitt entbunden. Es wurden 2 intrauterine fetale Todesfälle beobachtet. Keines der Neugeborenen wurde bei der Geburt positiv auf SARS-CoV‑2 getestet. [Publisher, German] Das peripartale Management erfordert eine enge interdisziplinäre Zusammenarbeit und sollte in der Frühschwangerschaft vorrangig auf das mütterliche Überleben ausgerichtet sein. Die Bauchlagerung, ein wesentlicher, evidenzbasierter Eckpfeiler in der Therapie des akuten Atemnotsyndroms (ARDS), kann auch in fortgeschrittenen Schwangerschaftsstadien sicher angewendet werden. Inhalatives Stickstoffmonoxid (iNO) und extrakorporale Membranoxygenierung (ECMO) sollten als lebensrettende Behandlungsoptionen für sorgfältig ausgewählte Patientinnen in Betracht gezogen werden.

Date Created: 20240426 Date Completed: 20240610 Latest Revision: 20240819

20240819

PMC11164748

10.1007/s00101-024-01405-5

38671334