pregnancy in the time of covid-19 · 7/8/2020 · case presentation gp is a 36 y/o g4 p1021 ga 240...
TRANSCRIPT
Pregnancy
in the
Time of
COVID-19
Maternal-Fetal Medicine
KUSM-Wichita
I have no conflicts of interest to report.
Objectives
Pathogenesis
Case Presentation
Symptoms
Treatment
Management in Pregnancy
ID
Case Presentation
GP is a 36 y/o G4 P1021 GA 240 weeks that
tested + for COVID-19 5 days PTA
Transferred for worsening SOB x 2 days
with O2 sats in the 80s on 5L O2 per NC
VS: T 973, P 107 BP 112/56
PMHx: T2DM, previous C/S x1
Transferred to MICU for increasing distress
Pt desired C/S for Ob indications
Intubated about 4 hours after admission
ABGs 7.09/45/87/3.4/95%;base xs -15.9
Labs: Creatinine 0.6, lymphocytes 12.6%
CRP>1900, d-dimer 2020, AST 102,
glucose 378, HgbA1c 10.2%
Started on dexamethasone, therapeutic
heparin, insulin pump, bicarbonate,
pressors, broad-spectrum antibiotics
CXR: bilateral confluent opacities, R>L
Tube feedings
Continuous renal replacement therapy
Convalescent plasma x 2
Kept paralyzed/sedated in prone position
Tocilizumab
Remdesivir
Labile BPs
DKA resolved HD #4
Escaped delivery
D/Ced dialysis HD #9
Extubated HD #21
Discharged undelivered on HD #39
Pathogenesis
Pathogenesis
Pathogenesis
ACE-2 suspected receptor for COVID-19
ACE-2 receptors primarily in Type 2
alveolar cells
Found throughout aerodigestive tract
ACE-2 receptors attenuated in women
Inflammatory Response
Cytokine Storm
Defective immune response
Overproduction of pro-inflammatory cytokines
Damages lung infrastructure
Cytokine storm circulates to other organs
Multi-organ failure
Symptoms & Severities
Symptoms
Fever or chills
Cough
Fatigue
Shortness of breath or difficulty breathing
Symptoms
Headache
Sore throat
Muscle/body aches
New loss of taste or smell
Symptoms
Diarrhea
Nausea or voming
Congestion or runny nose
Testing
Antigen Testing
Point of care tests
Send to lab
What We Have at WMC
Abbott ID NOW COVID-19
Sensitivity: 91% [95% CI 0.76-0.97]
DiaSorin Molecular Simplexa COVID-19
Sensitivity: 100% [95% CI 0.98-1.00]
Am J Clin Pathol 2020. DOI:10.1093/ajcp/aqaa097
Cepheid Xpert Xpress SARS-CoV-2
Severity of Symptoms
China
Study*
Ob
Study
Mild
Severe
Critical
*International Journal of Surgery 77 (2020) 206-16.
81%
14%
5%
Am J Obstet Gynecol MFM 2020.
doi.org/10.1016/j.ajog.mf.2020.100118
86%
9.3%
4.7%
Incubation period up to 14 days
Median time of 4-5 days from exposure to
symptoms onset
Presymptomatic/Asymptomatic
Presymptomatic/Asymptomatic
Close Monitoring
Daily self-assessments
Telehealth an option
Mild Disease
Presence of symptoms:
• Cough
• Fever responsive to acetaminophen
• Myalgias
• Loss of taste or smell
• NONE of the following:
• Dyspnea/tachypnea
• Abnormal chest imaging
Mild Disease
• Consider inpatient management if
comorbidities are present:
• Uncontrolled hypertension
• Suboptimally controlled GDM/ or
pregestational diabetes
• Chronic renal/cardiopulmonary disease
• Immunosuppression
Stay away from other people/pets for 14 days
Avoid public transportation
Monitor symptoms
Keep in touch with your provider
Get rest & stay hydrated
Emergency Warning Signs
Trouble breathing
New confusion
Cyanosis
Inability to wake or stay awake
Persistent pain/pressure in chest
Preterm contractions, vaginal bleeding, or
decreased fetal movement
Call your provider’s office, 911 or medical
facility that you may (do) have COVID-19
before showing up & wear a mask
Supportive Care with Mild Disease
Conservative fluid management
O2 therapy to keep sats >94%
VTE prophylaxis?
Prone positioning
Consult Infectious Disease
Prone Positioning
Moderate Disease
Presence of symptoms with any of:
Fever despite acetaminophen
Dyspnea/tachypnea
Abnormal chest imaging
Abnormal ABGs
Unable to maintain O2 sats > 94%
Needs Hospitalization
Vital signs q 2-8 hours
Continuous pulse oximetry
Early warning signs:
Increased dyspnea or work at breathing
Inability to maintain O2 sats
Persistent or more frequent fevers
Worsening of myalgias
Treatment
Arterial Blood Gases in Pregnancy
Parameter Non-pregnant Pregnant 2nd & 3rd
adult trimester
pH 7.35-7.45 7.40-7.49
PaO2 (mmHg) 80-100 90-110
PCO2 (mmHg) 35-45 25-33
HCO3 (mEq/L) 21-30 16-22
Normal state in pregnancy is a compensated
respiratory alkalosis
Laboratory Evaluation
Lymphopenia
Leukocytosis
Elevated CRP, LDH, D-dimer
Elevated LFTs & creatinine may be
evidence of end-organ damage
Procalcitonin
Moderate to Severe Disease
Nasal cannula: maximum 15 L/min
Non-rebreather face mask: 15 L/min
High-flow nasal cannula: 60 L/min
You might want to make sure someone with
intubating skills is aware of the situation
Venturi face mask: FiO2 maximum of
60% oxygen delivery
Severe Disease
>50% lung involvement on imaging
RR > 30 bpm
O2 sats <93%
Ratio of PaO2/FiO2 <300
Severe Disease: Admission to ICU
Inability to maintain O2 sats >95% with
supplemental O2
New end-organ dysfunction
Intensivist/critical care team consultation
Critical Disease
Hypotension (MAP <65) despite adequate
fluid resuscitation
Multi-organ failure or dysfunction
Respiratory failure requiring mechanical
ventilation
Therapeutics
On June 15, 2020; the FDA revoked
the EUA for both drugs
Randomized, controlled open-labelled trial
in 176 hospitals in the UK
Dexamethasone 6 mg po or iv daily x 10 days
If pregnant or breastfeeding, received
methylprednisolone 40 mg po or
hydrocortisone 80 mg iv bid
Decreased mortality if intubated by about 1/3
& if only requiring O2, mortality decreased by
1/5
Corticosteroids
Convalescent Plasma Transfusion (CPT)
K Rajendran et al. J Med Virol.2020;1-9
27 total patients; 17 had ARDS & 7 on ECMO
CPT significantly reduced viral load &
increased level of neutralizing antibodies
ARDS resolved & off ventilation within 1 to
maximum of 35 days after CPT
Zero mortality
Can’t make definitive conclusion on optimal
doses & treatment time point for CPT
Remdesivir Phase III Trial Begins
for Moderate Disease
Open-label study
Remdesivir for 5 or 10 days v.
standard of care
5-day group: 65% more likely to have
clinical improvement at day 11
OR 1.65 [95% CI 1.09-2.48]
10-day group trended towards improvement
Remdesivir for Severe COVID-19
J. Grein et al. N Engl J Med 04/10/2020 DOI:10.1056/NEJM oa2007016
53 patients: received Remdesivir 200 mg iv
on day 1, followed by 100 mg iv qd x 9 days
At baseline, 30 pts. (57%) were on mechanical
ventilation and 4 (8%) on ECMO
Improvement in 36/53 patients (68%)
Mortality rate of 13% (7 patients)
Anticoagulation & COVID-19
Patients who are critically ill or on
mechanical ventilation should receive
thromboprophylaxis
Some advocate using CRP &/or D-dimer
to guide management
No clinical data to suggest that early,
full-dose anticoagulation is beneficial
What About the Fetus?
Fetal & tocodynamometer monitoring
should be used when fetal intervention,
including delivery, would be considered
based on GA, fetal/maternal status &
maternal preferences
Unknown if COVID-19 transmitted vertically
or via breast milk
AP testing for usual Ob indications
Delivery in the Critically Ill Patient
Should be individualized on maternal &
fetal status
Mechanical ventilation NOT an indication
for delivery
In the 3rd trimester, unclear whether
delivery provides an improvement in
ventilation
Delivery in the Asymptomatic/
Mildly Symptomatic Patient
+COVID-19 status not indication for delivery
Patient should wear mask
PPE needed for health care providers
Consider early epidural to prevent need for
intubation
Mode of delivery as per Ob indications
Delivery in the Asymptomatic/
Mildly Symptomatic Patient
37 0/7 weeks-38 6/7 weeks, expectant
management until 14 days after PCR test
positive or 7 days after symptoms
started & 3 days after resolution of
symptoms
Delivery at 39 weeks GA or after, delivery
may be considered to decrease risk of
worsening maternal status
Mother with COVID-19
CDC/WMC recommend that symptomatic
COVID + patients be separated from infant
Infant to be tested 24-48 hours post-delivery
After hand hygiene while wearing mask,
a non-infected support person may feed
expressed breastmilk to infant
Asymptomatic Mothers with + COVID-19
Option 1: separate rooms
Option 2: room-in together
6 ’ apart, ideally separated by curtain
Bathe infant ASAP to remove potential
virus from skin
Masked healthy support person caring for infant
Concluding Thoughts
As data collected, best practices will
continue to evolve
Unknown if COVID-19 transmitted vertically
or by breastmilk
Telemedicine when able
Consultation when appropriate
Questions?