Covid-19 associated ARDS in pregnant women and timing of delivery: a single center experience,Critical Care

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Covid-19 associated ARDS in pregnant women and timing of delivery: a single center experience
Critical Care ( IF 8.8 ) Pub Date : 2022-09-13 , DOI: 10.1186/s13054-022-04145-3
Markus Busch ₁ , Marius M Hoeper _{2,

3} , Constantin von Kaisenberg ₄ , Thomas Stueber ₅ , Klaus Stahl ₁

Affiliation

The SARS-CoV-2 pandemic resulted in an unprecedented number of severe cases among pregnant women [1, 2]. To date, there have been only few reports of the specific issues that arise during the intensive care treatment of pregnant women with lung failure due to Covid-19 [3, 4]. Complex medical decision-making is required in the management of critically ill pregnant women [5] and further data is needed to guide prognostication of outcomes and clinical decision making.

We here present a case series of 14 pregnant and peripartum women with severe acute respiratory distress syndrome (ARDS) due to Covid-19 treated at our institution between January 2020 and December 2021.

Figure 1 summarizes the different ICU courses; Table 1 displays the maternal characteristics. Figure 2 displays the individual ICU course of included patients. The median maternal age was 31 years (Interquartile Range (IQR) 28–37) and the median gestational age on ICU admission 26 weeks (22–32). The median ICU length of stay was 14 days (6–34) days, 13/14 (92.8%) women had severe and 1/14 (12.5%) had moderate ARDS, the median PaO₂/FiO₂ (PF ratio) on admission was 74 mmHg (60–93).

Table 1 Patient characteristics

Full size table

10/14 (71.4%) women required invasive mechanical ventilation, 6/14 (42.8%) with additional extracorporeal membrane oxygenation (ECMO). 4/14 (28.5%) patients could be managed with non-invasive support, 3/14 (21.4%) with high flow nasal cannula (HFNC) and 1/14 (7.1%) with non-invasive ventilation (NIV). Prone positioning was used in 5/14 (35.7%) patients. Specific Covid-19 therapies included Remdesivir in 3/14 (21.4%), Tocilizumab in 5/14 (35.7%) and Glucocorticoids in 12/14 (85.7%).

7/14 (50%) women had isolated ARDS in pregnancy and another 7/14 (50%) had multi organ failure (MOF), defined by additional non-pulmonary organ specific sub-SOFA scores ≥ 2 points. In 3/14 (21.4%) MOF developed after delivery of women with previously isolated ARDS.

Considering all MOF together, the second most common organ failure besides ARDS was circulatory failure in 10/14 (71%) women. Kidney failure was present in 5/14 (36%) women. In 4/14 (29%) there was maternal cardiac failure, 3/14 (21.4%) with predominant left heart and one right heart failure, and 2/14 (14.2%) required additional arterial ECMO cannulation for circulatory support.

None of the 7/14 (50%) patients with isolated ARDS during pregnancy died. In 3/14 (21.4%) women, caesarean section was performed while on the ICU between gestational weeks 33 and 38 due to progressive respiratory failure. These women and their offspring survived but all 3 women developed MOF after delivery. All maternal and fetal deaths occurred in patients with MOF who required high-dose catecholamine support: 2/14 (14.2%) of the women and 4/14 (28.5%) of the unborn died. Two intrauterine fetal deaths (IUFD) occurred in the setting of maternal MOF at 21 and 28 weeks’ gestation, respectively. One stillbirth occurred at gestational week 17 after maternal recovery from MOF, and one patient requested abortion at 30 weeks’ gestation after she had already left ICU because her child displayed severe ischemic brain damage presumably resulting from maternal MOF and profound shock.

All 7/14 (50%) women with MOF were before 28 weeks’ gestation, 3/14 (21.4%) were before gestational week 24, before viability, thus delivery was not a reasonable option. The other 4/14 (28.5%) patients with MOF were between gestational week 26 and 28. In these patients, emergency caesarean section was discussed on a daily basis within a multidisciplinary team consisting of critical care and obstetric professionals.

In summary, the management of pregnant patients with severe Covid 19 is complex and requires a multidisciplinary approach. Despite the relatively small sample size, our data suggest that patients with severe Covid-19-related ARDS can be successfully carried through pregnancy with invasive ventilation and ECMO, if needed, as long as they suffer from isolated lung failure. However, the risk of maternal and fetal death increases substantially once MOF develops. Additional circulatory failure requiring high-dose catecholamine support seems to be the major determinant of adverse maternal and fetal outcome in pregnant women with severe Covid-19 associated ARDS.

The decision regarding delivery in women with severe Covid-19 associated ARDS needs to balance multiple risks and benefits, including the risk of prematurity to the fetus, the potential to improve or worsen maternal respiratory status with delivery, and the risks accompanying major surgery such as cesarean section, particularly in patients requiring ECMO support. These preliminary observations need to be tested in larger multicenter studies.

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Kayem G, Lecarpentier E, Deruelle P, Bretelle F, Azria E, Blanc J, Bohec C, Bornes M, Ceccaldi PF, Chalet Y, Chauleur C, Cordier AG, Desbriere R, Doret M, Dreyfus M, Driessen M, Fermaut M, Gallot D, Garabedian C, Huissoud C, Luton D, Morel O, Perrotin F, Picone O, Rozenberg P, Sentilhes L, Sroussi J, Vayssiere C, Verspyck E, Vivanti AJ, Winer N, Alessandrini V, Schmitz T. A snapshot of the Covid-19 pandemic among pregnant women in France. J Gynecol Obstet Hum Reprod. 2020;49(7):101826. https://doi.org/10.1016/j.jogoh.2020.101826.
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Authors and Affiliations

Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Str.1, 30625, Hannover, Germany
Markus Busch & Klaus Stahl
Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
Marius M. Hoeper
German Centre for Lung Research, Hannover, Germany
Marius M. Hoeper
Department of Obstetrics, Gynecology and Reproductive Medicine, Hannover Medical School, Hannover, Germany
Constantin von Kaisenberg
Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
Thomas Stueber

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Thomas StueberView author publications
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Klaus StahlView author publications
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Contributions

MB collected the data and wrote the original draft. MMH, CK, TS and KS reviewed and edited the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Markus Busch.

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The authors declare that they have no competing interests.

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Busch, M., Hoeper, M.M., von Kaisenberg, C. et al. Covid-19 associated ARDS in pregnant women and timing of delivery: a single center experience. Crit Care 26, 275 (2022). https://doi.org/10.1186/s13054-022-04145-3

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Received: 25 July 2022
Accepted: 29 July 2022
Published: 13 September 2022
DOI: https://doi.org/10.1186/s13054-022-04145-3

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中文翻译：

孕妇中与 Covid-19 相关的 ARDS 和分娩时间：单一中心的经验

SARS-CoV-2 大流行导致孕妇出现空前数量的严重病例 [1, 2]。迄今为止，关于因 Covid-19 导致肺衰竭的孕妇在重症监护治疗期间出现的具体问题的报道很少 [3, 4]。危重孕妇的管理需要复杂的医疗决策[5]，需要进一步的数据来指导预后的预测和临床决策。

我们在此介绍了 2020 年 1 月至 2021 年 12 月期间在我们机构接受治疗的 14 名因 Covid-19 导致严重急性呼吸窘迫综合征 (ARDS) 的孕妇和围产期妇女的病例系列。

图 1 总结了不同的 ICU 课程；表 1 显示了母体特征。图 2 显示了纳入患者的个体 ICU 病程。产妇中位年龄为 31 岁（四分位距 (IQR) 28-37），入住 ICU 时的中位孕周为 26 周（22-32 周）。中位 ICU 住院时间为 14 天 (6-34) 天，13/14 (92.8%) 的女性患有重度 ARDS，1/14 (12.5%) 的女性患有中度 ARDS，中位 PaO ₂ /FiO ₂ (PF 比)入院为 74 mmHg (60-93)。

表 1 患者特征

全尺寸表

10/14 (71.4%) 的女性需要有创机械通气，6/14 (42.8%) 的女性需要额外的体外膜肺氧合 (ECMO)。4/14 (28.5%) 的患者可以接受无创支持，3/14 (21.4%) 的患者可以接受高流量鼻导管 (HFNC)，1/14 (7.1%) 的患者可以接受无创通气 (NIV)。5/14 (35.7%) 的患者使用俯卧位。特定的 Covid-19 疗法包括 3/14 的瑞德西韦（21.4%）、5/14 的托珠单抗（35.7%）和 12/14 的糖皮质激素（85.7%）。

7/14 (50%) 的女性在妊娠期间患有孤立性 ARDS，另有 7/14 (50%) 的女性患有多器官衰竭 (MOF)，其定义为额外的非肺器官特异性 sub-SOFA 评分 ≥ 2 分。在 3/14 (21.4%) 中，MOF 是在先前孤立的 ARDS 女性分娩后发生的。

综合考虑所有 MOF，除 ARDS 外，第二常见的器官衰竭是 10/14 (71%) 女性的循环衰竭。5/14 (36%) 的女性出现肾功能衰竭。4/14 (29%) 的产妇出现心力衰竭，3/14 (21.4%) 主要是左心衰竭和 1 名右心衰竭，2/14 (14.2%) 需要额外的动脉 ECMO 插管以支持循环。

7/14 (50%) 例妊娠期间孤立性 ARDS 患者均未死亡。在 3/14 (21.4%) 的女性中，由于进行性呼吸衰竭，在妊娠 33 至 38 周期间在 ICU 进行了剖宫产。这些妇女及其后代幸存下来，但所有 3 名妇女在分娩后都出现了 MOF。所有孕产妇和胎儿死亡均发生在需要大剂量儿茶酚胺支持的 MOF 患者中：2/14 (14.2%) 的女性和 4/14 (28.5%) 的未出生婴儿死亡。分别在妊娠 21 周和 28 周时在母体 MOF 环境中发生了两次宫内胎儿死亡 (IUFD)。在母亲从 MOF 恢复后的妊娠第 17 周发生了一次死产，

所有 7/14 (50%) 的 MOF 女性都在妊娠 28 周之前，3/14 (21.4%) 的女性在妊娠 24 周之前，在存活之前，因此分娩不是一个合理的选择。其他 4/14 (28.5%) 的 MOF 患者在妊娠 26 至 28 周之间。在这些患者中，由重症监护和产科专业人员组成的多学科团队每天讨论紧急剖宫产。

总之，重症 Covid 19 孕妇的管理很复杂，需要多学科的方法。尽管样本量相对较小，但我们的数据表明，患有严重 Covid-19 相关 ARDS 的患者可以在需要时通过有创通气和 ECMO 成功完成妊娠，只要他们患有孤立性肺衰竭。然而，一旦 MOF 发展，孕产妇和胎儿死亡的风险就会大大增加。需要大剂量儿茶酚胺支持的额外循环衰竭似乎是严重 Covid-19 相关 ARDS 孕妇母婴不良结局的主要决定因素。

对患有严重 Covid-19 相关 ARDS 的妇女进行分娩的决定需要平衡多种风险和益处，包括胎儿早产的风险、分娩时改善或恶化产妇呼吸状况的可能性，以及伴随大手术的风险，例如剖宫产，尤其是需要 ECMO 支持的患者。这些初步观察结果需要在更大的多中心研究中进行检验。

当前研究期间使用和分析的数据集可根据合理要求从相应作者处获得。

Kayem G，Lecarpentier E，Deruelle P，Bretelle F，Azria E，Blanc J，Bohec C，Bornes M，Ceccaldi PF，Chalet Y，Chauleur C，Cordier AG，Desbriere R，Doret M，Dreyfus M，Driessen M，Fermaut M , Gallot D, Garabedian C, Huissoud C, Luton D, Morel O, Perrotin F, Picone O, Rozenberg P, Sentilhes L, Sroussi J, Vayssiere C, Verspyck E, Vivanti AJ, Winer N, Alessandrini V, Schmitz T. A法国孕妇中 Covid-19 大流行的快照。J Gynecol Obstet Hum Reprod。2020；49(7):101826。https://doi.org/10.1016/j.jogoh.2020.101826。
文章 PubMed PubMed Central Google Scholar
(CDC) CfDCaP。怀孕期间有关 COVID-19 的数据。2022. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/special-populations/pregnancy-data-on-covid-19.html。
Schnettler WT、Al Ahwel Y、Suhag A. 2019 年感染冠状病毒病的妊娠中的严重急性呼吸窘迫综合征：产科和重症监护注意事项。Am J Obstet Gynecol。2020;2(3):100120。https://doi.org/10.1016/j.ajogmf.2020.100120。
文章谷歌学术
Morau E, Bouvet L, Keita H, Vial F, Bonnet MP, Bonnin M, Le Gouez A, Chassard D, Mercier FJ, Benhamou D, Obstetric A, Critical Care Club Working G. COVID-期间产科的麻醉和重症监护19 流行病。Anaesth Crit Care 疼痛医学。2020;39(3):345-9。https://doi.org/10.1016/j.accpm.2020.05.006。
文章 PubMed PubMed Central Google Scholar
Zieleskiewicz L, Chantry A, Duclos G, Bourgoin A, Mignon A, Deneux-Tharaux C, Leone M. 重症监护和妊娠：妊娠期间产科 ICU 患者管理的流行病学和一般原则。Anaesth Crit Care 疼痛医学。2016；35（增刊 1）：S51-7。https://doi.org/10.1016/j.accpm.2016.06.005。
文章 PubMed 谷歌学术

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作者和附属机构

汉诺威医学院胃肠病学、肝病学和内分泌学系, Carl-Neuberg-Str.1, 30625, Hannover, Germany
马库斯·布施和克劳斯·斯塔尔
德国汉诺威汉诺威医学院呼吸内科
马吕斯·M·霍珀
德国肺研究中心，汉诺威，德国
马吕斯·M·霍珀
德国汉诺威汉诺威医学院妇产科和生殖医学系
康斯坦丁·冯·凯森伯格
德国汉诺威汉诺威医学院麻醉学和重症监护医学系
托马斯·斯图伯

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