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Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study.
Am J Obstet Gynecol MFM. 2020 08; 2(3):100134.AJ

Abstract

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.

Authors+Show Affiliations

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY.Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, NY.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, NY.Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine, Mount Sinai, New York, NY.Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine, Mount Sinai, New York, NY.Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine, Mount Sinai, New York, NY.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA.Department of Obstetrics and Gynecology, Saint Barnabas Medical Center, Livingston, NJ.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.Division of Maternal-Fetal Medicine, TriHealth Good Samaritan Hospital, Cincinnati, OH.Division of Maternal-Fetal Medicine, TriHealth Good Samaritan Hospital, Cincinnati, OH.Department of Obstetrics and Gynecology, Crozer Chester Medical Center, Chester, PA.Department of Obstetrics and Gynecology, Crozer Chester Medical Center, Chester, PA.Department of Obstetrics and Gynecology, Einstein Healthcare Network, Philadelphia, PA.Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

32391519

Citation

Pierce-Williams, Rebecca A M., et al. "Clinical Course of Severe and Critical Coronavirus Disease 2019 in Hospitalized Pregnancies: a United States Cohort Study." American Journal of Obstetrics & Gynecology MFM, vol. 2, no. 3, 2020, p. 100134.
Pierce-Williams RAM, Burd J, Felder L, et al. Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study. Am J Obstet Gynecol MFM. 2020;2(3):100134.
Pierce-Williams, R. A. M., Burd, J., Felder, L., Khoury, R., Bernstein, P. S., Avila, K., Penfield, C. A., Roman, A. S., DeBolt, C. A., Stone, J. L., Bianco, A., Kern-Goldberger, A. R., Hirshberg, A., Srinivas, S. K., Jayakumaran, J. S., Brandt, J. S., Anastasio, H., Birsner, M., O'Brien, D. S., ... Berghella, V. (2020). Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study. American Journal of Obstetrics & Gynecology MFM, 2(3), 100134. https://doi.org/10.1016/j.ajogmf.2020.100134
Pierce-Williams RAM, et al. Clinical Course of Severe and Critical Coronavirus Disease 2019 in Hospitalized Pregnancies: a United States Cohort Study. Am J Obstet Gynecol MFM. 2020;2(3):100134. PubMed PMID: 32391519.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study. AU - Pierce-Williams,Rebecca A M, AU - Burd,Julia, AU - Felder,Laura, AU - Khoury,Rasha, AU - Bernstein,Peter S, AU - Avila,Karina, AU - Penfield,Christina A, AU - Roman,Ashley S, AU - DeBolt,Chelsea A, AU - Stone,Joanne L, AU - Bianco,Angela, AU - Kern-Goldberger,Adina R, AU - Hirshberg,Adi, AU - Srinivas,Sindhu K, AU - Jayakumaran,Jenani S, AU - Brandt,Justin S, AU - Anastasio,Hannah, AU - Birsner,Meredith, AU - O'Brien,Devon S, AU - Sedev,Harish M, AU - Dolin,Cara D, AU - Schnettler,William T, AU - Suhag,Anju, AU - Ahluwalia,Shabani, AU - Navathe,Reshama S, AU - Khalifeh,Adeeb, AU - Anderson,Kathryn, AU - Berghella,Vincenzo, Y1 - 2020/05/08/ PY - 2020/04/27/received PY - 2020/05/04/accepted PY - 2020/5/12/pubmed PY - 2020/5/12/medline PY - 2020/5/12/entrez KW - COVID-19 KW - SARS-CoV-2 KW - coronavirus KW - pregnancy SP - 100134 EP - 100134 JF - American journal of obstetrics & gynecology MFM JO - Am J Obstet Gynecol MFM VL - 2 IS - 3 N2 - 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. SN - 2589-9333 UR - https://www.unboundmedicine.com/medline/citation/32391519/Clinical_course_of_severe_and_critical_coronavirus_disease_2019_in_hospitalized_pregnancies:_a_United_States_cohort_study_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S2589-9333(20)30077-X DB - PRIME DP - Unbound Medicine ER -