Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Hebrew University Ein Karem Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
Department of Obstetrics and Gynecology, Hadassah Hebrew University Ein Karem Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
Lancet Respir Med. 2023 Jun;11(6):520-529. doi: 10.1016/S2213-2600(22)00491-X. Epub 2023 Feb 3.
A key unresolved controversy in severe COVID-19 pneumonitis in pregnancy is the optimum timing of delivery and whether delivery improves or worsens maternal outcomes. We aimed to assess clinical data on every intensive care unit (ICU) day for pregnant and postpartum women admitted to the ICU with COVID-19, with a particular focus on the days preceding and following delivery.
In this multicentre, nationwide, prospective and retrospective cohort study, we evaluated all pregnant women who were admitted to an ICU in Israel with severe COVID-19 pneumonitis from the 13th week of gestation to the 1st week postpartum. We excluded pregnant patients in which the ICU admission was unrelated to severe COVID-19 pneumonitis. We assessed maternal and neonatal outcomes and longitudinal clinical and laboratory ICU data. The primary overall outcome was maternal outcome (worst of the following: no invasive positive pressure ventilation [IPPV], use of IPPV, use of extracorporeal membrane oxygenation [ECMO], or death). The primary longitudinal outcome was Sequential Organ Failure Assessment (SOFA) score, and the secondary longitudinal outcome was the novel PORCH (positive end-expiratory pressure [PEEP], oxygenation, respiratory support, chest x-ray, haemodynamic support) score. Patients were classified into four groups: no-delivery (pregnant at admission and no delivery during the ICU stay), postpartum (ICU admission ≥1 day after delivery), delivery-critical (pregnant at admission and receiving or at high risk of requiring IPPV at the time of delivery), or delivery-non-critical (pregnant at admission and not critically ill at the time of delivery).
From Feb 1, 2020, to Jan 31, 2022, 84 patients were analysed: 34 patients in the no-delivery group, four in postpartum, 32 in delivery-critical, and 14 in delivery-non-critical. The delivery-critical and postpartum groups had worse outcomes than the other groups: 26 (81%) of 32 patients in the delivery-critical group and four (100%) of four patients in the postpartum group required IPPV; 12 (38%) and three (75%) patients required ECMO, and one (3%) and two (50%) patients died, respectively. The delivery-non-critical and no-delivery groups had far better outcomes than other groups: six (18%) of 34 patients and two (14%) of 14 patients required IPPV, respectively; no patients required ECMO or died. Oxygen saturation (SpO), SpO to fraction of inspired oxygen (FiO) ratio (S/F ratio), partial pressure of arterial oxygen to FiO ratio (P/F ratio), ROX index (S/F ratio divided by respiratory rate), and SOFA and PORCH scores were all highly predictive for adverse maternal outcome (p<0·0001). The delivery-critical group deteriorated on the day of delivery, continued to deteriorate throughout the ICU stay, and took longer to recover (ICU duration, Mantel-Cox p<0·0001), whereas the delivery-non-critical group improved rapidly following delivery. The day of delivery was a significant covariate for PORCH (p<0·0001) but not SOFA (p=0·09) scores.
In patients who underwent delivery during their ICU stay, maternal outcome deteriorated following delivery among those defined as critical compared with non-critical patients, who improved following delivery. Interventional delivery should be considered for maternal indications before patients deteriorate and require mechanical ventilation.
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在妊娠合并严重 COVID-19 肺炎中，一个尚未解决的关键争议是最佳分娩时机，以及分娩是改善还是恶化产妇结局。我们旨在评估因 COVID-19 入住 ICU 的孕妇和产后妇女的每一个 ICU 日的临床数据，特别关注分娩前后的天数。
在这项多中心、全国性、前瞻性和回顾性队列研究中，我们评估了以色列所有因严重 COVID-19 肺炎入住 ICU 的孕妇，从妊娠第 13 周至产后第 1 周。我们排除了 ICU 入院与严重 COVID-19 肺炎无关的孕妇。我们评估了母婴结局以及纵向临床和实验室 ICU 数据。主要整体结局是产妇结局（以下情况最糟：无有创正压通气[IPPV]、使用 IPPV、使用体外膜氧合[ECMO]或死亡）。主要纵向结局是序贯器官衰竭评估（SOFA）评分，次要纵向结局是新型 PORCH（呼气末正压[PEEP]、氧合、呼吸支持、胸部 X 线、血流动力学支持）评分。患者分为四组：无分娩（入院时妊娠且 ICU 期间无分娩）、产后（ICU 入院≥1 天后分娩）、分娩危急（入院时妊娠且分娩时接受或有高危需要 IPPV）或分娩非危急（入院时妊娠且分娩时病情不危急）。
从 2020 年 2 月 1 日至 2022 年 1 月 31 日，分析了 84 名患者：34 名无分娩组、4 名产后组、32 名分娩危急组和 14 名分娩非危急组。分娩危急组和产后组的结局比其他组差：32 名分娩危急组患者中有 26 名（81%）需要 IPPV；4 名产后组患者均需要 IPPV；12 名（38%）和 3 名（75%）患者需要 ECMO，分别有 1 名（3%）和 2 名（50%）患者死亡。分娩非危急组和无分娩组的结局明显好于其他组：34 名患者中有 6 名（18%）和 14 名患者中有 2 名（14%）需要 IPPV；没有患者需要 ECMO 或死亡。氧饱和度（SpO）、SpO 与吸入氧分数（FiO）比值（S/F 比值）、动脉氧分压与 FiO 比值（P/F 比值）、ROX 指数（S/F 比值除以呼吸频率）以及 SOFA 和 PORCH 评分均对不良母婴结局有高度预测性（p<0·0001）。分娩危急组在分娩当天恶化，整个 ICU 期间持续恶化，且恢复时间更长（ICU 持续时间，Mantel-Cox p<0·0001），而分娩非危急组在分娩后迅速改善。分娩日是 PORCH（p<0·0001）但不是 SOFA（p=0·09）评分的显著协变量。
在 ICU 住院期间分娩的患者中，与非危急患者相比，危急患者的产妇结局在分娩后恶化，而后者在分娩后改善。在患者恶化并需要机械通气之前，应考虑因母体指征进行干预性分娩。
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