Rapid overview of the care of the pregnant COVID-19 patient with severe or critical respiratory disease

• NIH criteria for severe COVID-19 (any of the following):
  • Sustained respiratory frequency >30 breaths per minute
  • SpO₂ <94% on room air at sea level
  • Ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO₂/FiO₂) <300
  • Lung infiltrates >50%
• NIH criteria for critical COVID-19 (any of the following):
  • Respiratory failure (acute respiratory distress syndrome)
  • Septic shock
  • Multiple organ dysfunction

• Options include:
  • Low- or high-flow oxygen
  • Prone position
  • Noninvasive positive-pressure ventilation
  • Mechanical ventilation
  • Subsequent interventions include recruitment maneuvers and high PEEP strategies, neuromuscular blocking agents, pulmonary vasodilators, and ECMO as a last resort

Escalate respiratory support as needed to achieve/maintain SpO₂ ≥95%. By comparison, the typical SpO₂ target in nonpregnant adults with COVID-19 who are receiving supplemental oxygen is 92 to 96%.

If the prone position is utilized, pillows/padding are used to ensure no pressure is exerted on the gravid abdomen.

• Dexamethasone 6 mg orally or IV once daily for 10 days or until discharge, whichever is shorter.

• Remdesivir

• In selected patients, other therapeutics recommended for nonpregnant adults with severe/critical COVID-19 and which may be considered in pregnancy include baricitinib (a JAK inhibitor) and tocilizumab (interleukin-6 antagonist), but there is no or minimal information on fetal risks.

Refer to UpToDate content on management of hospitalized adults with COVID-19 for detailed information.

• VTE prophylaxis:
  • In pregnant patients in whom urgent delivery is likely: prophylactic or intermediate dose unfractionated heparin SUBQ
  • In pregnant patients in whom urgent delivery is not likely: prophylactic or intermediate dose enoxaparin SUBQ

• Empiric treatment for influenza or bacterial pneumonia, when indicated.

• Obstetric ultrasound (eg, fetal number, fetal and placental position, gestational age, fetal weight, AFV)
• GBS culture in patients ≥23 weeks, begin penicillin G pending culture results for standard indications
• FHR monitoring:
  • 14 to <23 weeks: FHR check daily
  • ≥23 weeks: CTG at least daily

Refer to UpToDate content on prevention of early-onset neonatal GBS for detailed information.

• In general, if SpO₂ ≥95% can be achieved, even if maximum respiratory support is required, the pregnancy can be continued.
• Decision-making regarding delivery at the patient level depends on many factors, including:
  • The precise gestational age and plans for neonatal resuscitation.
  • The severity of hypoxemia.
  • The rate of disease progression and response to escalating therapy.
  • Results of tests of fetal well-being.
  • Comorbidities.
  • For pregnancies between 23 and 34 weeks of gestation, whether a course of antenatal corticosteroids has been completed.

• In the absence of contraindications to vaginal birth, a trial of labor is attempted if SpO₂ ≥95% can be achieved, even if maximum respiratory support is required.
• In patients >20 weeks of gestation who have a cardiac arrest, resuscitative cesarean delivery is advised.
• In patients with a fetal demise, the pregnancy is terminated by induction or by dilation and extraction, if a provider with the appropriate expertise is available.

• Fetal ultrasound:
  • At 18 to 20 weeks, if not already performed, and
  • At 32 weeks or 4 weeks after recovery (whichever occurs later in gestation)
• Routine prenatal care with delivery for standard obstetric indications.