Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study

      Background

      The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited.

      Objective

      This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2.

      Study Design

      This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24–48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported.

      Results

      Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m2. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission.

      Conclusion

      In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.

      Key words

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      References

        • Johns Hopkins University and Medicine Coronavirus Resource Center
        COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU).
        (Available at:)
        https://coronavirus.jhu.edu/map.html
        Date accessed: April 27, 2020
        • Wu Z.
        • McGoogan J.M.
        Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention.
        JAMA. 2020; ([Epub ahead of print])
        • Breslin N.
        • Baptiste C.
        • Gyamfi-Bannerman C.
        • et al.
        COVID-19 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals.
        Am J Obstet Gynecol MFM. 2020; ([Epub ahead of print])
        • Huang C.
        • Wang Y.
        • Li X.
        • et al.
        Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
        Lancet. 2020; 395: 497-506
        • Zhou F.
        • Yu T.
        • Du R.
        • et al.
        Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
        Lancet. 2020; 395: 1054-1062
        • Guan W.J.
        • Ni Z.Y.
        • Hu Y.
        • et al.
        Clinical characteristics of coronavirus disease 2019 in China.
        N Engl J Med. 2020; 382: 1708-1720
        • Liu D.
        • Li L.
        • Wu X.
        • et al.
        Pregnancy and perinatal outcomes of women with coronavirus disease (COVID-19) pneumonia: a preliminary analysis.
        AJR Am J Roentgenol. 2020; ([Epub ahead of print])
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        J Clin Epidemiol. 2008; 61: 344-349
        • The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team
        Vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020.
        China CDC Wkly. 2020; 2: 113-122
        • Society for Maternal-Fetal Medicine (SMFM)
        Electronic address: [email protected], Plante LA, Pacheco LD, Louis JM. SMFM Consult Series #47: sepsis during pregnancy and the puerperium.
        Am J Obstet Gynecol. 2019; 220: B2-B10
        • Hilton R.
        Defining acute renal failure.
        CMAJ. 2011; 183: 1167-1169
        • Bernal W.
        • Wendon J.
        Acute liver failure.
        N Engl J Med. 2013; 369: 2525-2534
        • Chen J.
        • Qi T.
        • Liu L.
        • et al.
        Clinical progression of patients with COVID-19 in Shanghai, China.
        J Infect. 2020; 80: e1-e6
        • Yang X.
        • Yu Y.
        • Xu J.
        • et al.
        Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study.
        Lancet Respir Med. 2020; 8: 475-481
        • Wu C.
        • Chen X.
        • Cai Y.
        • et al.
        Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China.
        JAMA Intern Med. 2020; ([Epub ahead of print])
        • Wang D.
        • Hu B.
        • Hu C.
        • et al.
        Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.
        JAMA. 2020; 323: 1061-1069
        • Kim E.S.
        • Chin B.S.
        • Kang C.K.
        • et al.
        Clinical course and outcomes of patients with severe acute respiratory syndrome coronavirus 2 infection: a preliminary report of the first 28 patients from the Korean cohort study on COVID-19.
        J Korean Med Sci. 2020; 35: e142
        • Henry B.M.
        • de Oliveira M.H.S.
        • Benoit S.
        • Plebani M.
        • Lippi G.
        Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis.
        Clin Chem Lab Med. 2020; ([Epub ahead of print])
        • Cheng B.
        • Jiang T.
        • Zhang L.
        • et al.
        Clinical characteristics of pregnant women with coronavirus disease 2019 in Wuhan, China.
        SSRN Electron J. 2020; (Available at: http://dx.doi.org/10.2139/ssrn.3555240. Accessed July 8, 2020)
        • Juusela A.
        • Nazir M.
        • Gimovsky M.
        Two cases of coronavirus 2019–related cardiomyopathy in pregnancy.
        Am J Obstet Gynecol MFM. 2020; ([Epub ahead of print])
        • Schnettler W.T.
        • Al Ahwel Y.
        • Suhag A.
        Severe ARDS in COVID-19-infected pregnancy: obstetric and intensive care considerations.
        Am J Obstet Gynecol MFM. 2020; ([Epub ahead of print])
        • Chen L.
        • Li Q.
        • Zheng D.
        • et al.
        Clinical characteristics of pregnant women with Covid-19 in Wuhan, China.
        N Engl J Med. 2020; ([Epub ahead of print])
        • Bhimraj A.
        • Morgan R.L.
        • Shumaker A.H.
        • et al.
        Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19.
        Clin Infect Dis. 2020; ([Epub ahead of print])
        • Mulangu S.
        • Dodd L.E.
        • Davey Jr., R.T.
        • et al.
        A randomized, controlled trial of Ebola virus disease therapeutics.
        N Engl J Med. 2019; 381: 2293-2303
        • Zaigham M.
        • Andersson O.
        Maternal and perinatal outcomes with COVID-19: a systematic review of 108 pregnancies.
        Acta Obstet Gynecol Scand. 2020; ([Epub ahead of print])
        • Karami P.
        • Naghavi M.
        • Feyzi A.
        • et al.
        Mortality of a pregnant patient diagnosed with COVID-19: a case report with clinical, radiological, and histopathological findings.
        Travel Med Infect Dis. 2020; ([Epub ahead of print])