Case Report
HJOG 2021, 20 (4), 213-220| doi: 10.33574/hjog.0306
Andria Syka1, Kyriakos Alexandrou2, Lakis Palazis3
1RN, BSc Nursing, MSc Health Management, Intensive Care Unit, Nicosia General Hospital, Limassol, Cyprus
2RN, BSc Nursing, MSc Community Health Care, Phd © Intensive Care Unit, Cardiopulmonary resuscitation services of the Ministry of Health, Cyprus
3MD, EDIC, M.P. Adm. Internal Medicine, Consultant Intensivist, Head ICU, Nicosia General Hospital, Nicosia, Cyprus
Correspondence: Andria Syka, RN, BSc Nursing, MSc Health Management, Intensive Care Unit, Nicosia General Hospital, Cyprus
Mosxatou 1 Agios Georgios Xabouzas, Limassol Cyprus, TK: 3071, e-mail: sikaantria@gmail.com
Abstract
An interdisciplinary and individualized approach should be implemented with regard to the management of severe COVID-19 in pregnancy. The present study deals with the clinical course of 2 pregnant women who have been diagnosed with this disease and needed admission to an ICU and mechanical respiratory support in Cyprus. The data collection took place in a general ICU of the General Hospital of Nicosia.In certain regions of the world, up to 15% of pregnant women were found to have a positive result on polymerase chain reaction testing for SARS-CoV-2 upon admission for delivery. While pregnant women do not appear to be at substantially higher risk of severe manifestations from COVID-19 compared with non-pregnant adults, the disease has resulted in severe maternal morbidity and mortality in both high- and low-resource settings.
Keywords: COVID-19,Critical care, Intensive care, ARDS, Pulmonology Respiratory disease, Pregnancy, Coronavirus
Introduction
Pregnant women are a vulnerable group of the population as they are more vulnerable to respiratory infections such as the flu. In addition, due to their reduced functional residual capacity, they are at increased risk of hypoxemia and the development of Acute Respiratory Difficulty Syndrome1. The anatomical and immunological changes that occur during pregnancy in conjunction with the disease require careful interdisciplinary strategy for the management of pregnant women with COVID-192.
The present study deals with the clinical course of 2 pregnant women who have been diagnosed with this disease and needed admission to an ICU and mechanical respiratory support in Cyprus. The data collection took place in a general ICU of the General Hospital of Nicosia. There is currently limited research data on the clinical course of women with severe disease3. According to the Centers for Disease Control and Prevention, COVID-19 does not appear to be associated with increased mortality among pregnant women compared to the general population, although pregnant women appear to be at increased risk of ICU admission and respiratory support1.
Case study
Case 1
This is a 30-year-old patient with a history of 20 weeks gestation who was diagnosed with covid – 19 on 8/7/21 (Table 1). On 7/18/21 she was admitted to a COVID-19 clinic with symptoms of cough and myalgia. Initially she was respiratory stable with low oxygen demand. Five days after admission, the need for respiratory support increased and treatment was started with High Flow Nasal Cannula (HNFO) with which she showed a partial response. She also presented atypical abdominal pain and epigastric pain and was evaluated by a gynecologist with an ultrasound without any particular findings. Three days after atypical abdominal pain showed further deterioration with intense shortness of breath and decreased hemoglobin saturation (SPO2). The patient was intubated and transferred to the Intensive Care Unit of the Nicosia General Hospital for further treatment. The patient was suppressed by continuous infusion of Propofol and analgesia by continuous infusion of fentanyl. Muscle relaxation was also given in continuous infusion with Rocuronium. After intubation, the patient status confirmed Severe Acute Respiratory Distress Syndrome (ARDS) and she was treated with protective mechanical ventilation. Assist Control-Volume Control mode was used with Inhaled Oxygen Mixture (FiO2- Fraction of Inspired Oxygen) 100%, (VT-Tidal Volume) 350 ml, Breathing Frequency (RR)) 25 per minute, Positive End Expiratory Pressure (PEEP) 12 cmH20 and PPleateau24,[Target value below 30, Compliance initially 19. During her hospitalization in the Intensive Care Unit she gratually improved with protective mechanical ventilation and without the need for a prone position. She was extubated on 7/27/21, initially with the need for a High Flow Nose Cannula (HFNO). She improved with physiotherapy and mobilization and was discharged with Venturi mask with Fio2 = 60% with good gas exchange. At the time of discharge the patient had a very good level of communication and was hemodynamically stable and without fever. A recent fever episode was treated by removing the central venous line and upgrading the antibiotic to piperacillin Tazobactam.
Case 2
This is a 30-year-old patient She was in her second pregnancy at 13 weeks, without a history of vaccination (Table 1). She was found positive in covid – 19 on 7/26/21, and she was admitted to the intensive care unit on 1/8/21, she was intubated due to shortness of breath and fever. Past medical history was positive for… possibly bronchial asthma. Her first pregnancy 6 years ago was delivered by caesarean section. When she was admitted to the Intensive Care Unit, she was sweating profusely, with sinus tachycardia, without hemodynamic instability During her hospitalization in the Intensive Care Unit, she improved her breathing with protective mechanical ventilation [Assist Control-Volume Control model was used, with breathing volume = 380 ml, PEEP = 12. In the evaluation of respiratory parameters he presented p-plateu 24, compliance = 35.]and was extubated on 4/8/21. After extubation she needed initially non-re-breathing mask and High Flow Nasal Canula with which she maintained good saturation. She improved with physiotherapy. She mobilized out of bed. She was discharged with a good level of communication, hemodynamically stable, she is taking ceftriaxone empirically without fever. On admission 2 pairs of blood culture were positive for staph epi. But were considered to be without clinical significance..A gynecologist was informed who confirmed that the fetus was normal for the week of pregnancy. A chest x-ray with protection of the fetus revealed a thickening in the right upper lung field.
Discussion
In this series of clinical cases, we describe two pregnant women with severe pneumonia, ARDS and mechanical ventilation due to COVID-19. Of these, both required mechanical ventilation. A CDC study of 8,207 pregnant women with SARS-CoV-2 in the United States found that pregnant women were at greater risk of being admitted to the ICU and mechanical ventilation than non-pregnant women of childbearing potential4.
Physiological changes during pregnancy increase the risk of acute respiratory failure and the need for mechanical respiratory support. The chest wall shrinks by about 30% during pregnancy. The risk of respiratory failure increases further with decreasing FRC5. Mechanical ventilation in pregnant women poses many challenges, including an increased risk of intubation failure due to increased airway swelling, reduced FRC6. Because of reduced chest wall compliance caused by the gravid uterus, increased plateau airway pressures may be noted, and careful attention to these pressures is required6.
Pulmonary ventilation in patients with ARDS includes Respiratory Volume 6 ml / kg of ideal body weight with a permissible range of 4-8ml per kg of ideal weight. Regarding the ventilation model, in most cases the Controlled Ventilation with Controlled Volume is chosen due to the fact that the Assist Control-Pressure Control ventilation must be closely monitored because there is a risk of increase of the respiratory volume beyond the acceptable one. Regarding the mechanical properties of the lung, the Plateau pressure must be less than 30cmH20 and drivind pressure [PPlateu -PEEP <12-15. The SPO2 target is 94-98% with the lowest possible FiO2. Target PCO2 is 30-32 to replicate normal physiology during pregnancy since pregnant women maintain a respiratory alkalosis due to respiratory stimulation by progesterone6.
At this stage in both cases there was no question of premature birth or miscarriage. In a series of cases of five pregnant women requiring endotracheal intubation, Hirshberg et al. (2020) reported three women who required preterm delivery due to deterioration of the mother’s respiratory status and improvement after delivery. In contrast, Hantoushzadeh et al. (2020) report seven maternal deaths due to COVID-19, six of which occurred after childbirth as part of a worsening clinical condition despite childbirth. In our case, in which conservative obstetric treatment was chosen, which included two women who needed mechanical ventilation and were discharged without requiring urgent childbirth.These cases, together with two similar cases described by Hirshberg et al., (2020) suggest that the mother’s clinical condition may improve without childbirth. Avoiding iatrogenic preterm births and associated morbidity and mortality is particularly important for women with a severe clinical picture of COVID-19 in older pregnancies.
Medication to prevent or treat certain conditions of the mother and fetus is an integral part of the obstetric care routine. The use of two classes of drugs has caused controversy during the COVID-19 pandemic: (1) prenatal corticosteroids. (2) MgSO4. Practice recommendations are summarized in Table 2.
There is strong evidence to support the use of a single cycle of prenatal corticosteroids (betamethasone or dexamethasone) in women at risk for preterm birth between 24 and 34 weeks of gestation. Prenatal corticosteroids have been shown to reduce the risk of perinatal death, respiratory distress syndrome, intra-abdominal bleeding, necrotic enterocolitis, need for respiratory support and admission to the neonatal intensive care unit (NICU), even in preterm infants9. More recent data suggest that the benefits of prenatal corticosteroids may be extended to infants born at 22-24 weeks10 and between 34 + 0 and 36 + 6 weeks11. However, not all guidelines recommend that they be used in extreme cases of prematurity.
Corticosteroids were associated with an increased risk of mortality in a systematic review of 30 studies that examined their use as adjunctive therapy for influenza12. However, this study included only one randomized controlled trial (RCT) and the reliability of the available data from observational studies was considered low due to the likelihood of confusion with indication.In addition, the doses used were 4-10 times higher than the standard dose given in pregnancy for fetal lung maturation13. In addition, a weak recommendation has been issued for the use of corticosteroids in patients with acute respiratory distress syndrome, based on indirect data14, and more recently, data from RCTs have shown that a corticosteroid regimen may be beneficial for some patients with COVID-19 pneumonia.
MgSO4 has been shown to be effective in preventing and treating seizures in preeclampsia at any gestational age15, and for fetal neuroprotection (reducing the risk of cerebral palsy) when administered to women at immediate risk of preterm delivery, especially weeks of pregnancy16. Although MgSO4 may be associated with an increased risk of maternal respiratory failure, no risk of respiratory failure has been demonstrated16. Several professional companies support the use of MgSO4 when indicated in pregnant women with COVID-19. An individual patient should be evaluated for the risks and benefits of using MgSO4, especially in women with hypoxia. Alternative dose regimens for neuroprotection could be considered on an individual basis, such as a single dose of 4 g MgSO4 intravenously. According to standard practice, the dose of MgSO4 should be adjusted in patients with acute renal impairment, which may be characteristic of COVID-1917.
Both pregnancy alone and covid-19 infection are associated with an increased risk of thrombotic complications, which is considered a cause of morbidity and mortality associated with COVID-1918. That is why in both cases they take enoxaparin sc daily or BD. The mechanism is probably multifactorial, although the interdependence between inflammation and the coagulation system, or thrombotic inflammation, appears to play an important role19. High rates of thrombotic complications have been reported in patients with severe and critical COVID-1920. These events are the result of at least two mechanisms: pulmonary microvascular thrombosis (immunothrombosis) and nosocomial venous thromboembolism (VTE)21. As pregnancy is a pre-thrombotic condition, the potential for increased risk of thrombosis in pregnant women with COVID-19 has become a matter of concern.However, published data do not suggest that pregnant women have an increased risk of COVID-19 associated thrombotic complications.
A recent announcement by the US Food and Drug Administration (FDA) on drug safety22 suggested that long-term maternal sedation may pose a potential risk to fetal neurodevelopment, although this report does not specifically mention ICU sedation The ACOG disputed this statement, identifying a lack of clinical data. Case reports describe the use of propofol during mechanical ventilation without significant damage other than hypotension with an associated reduction in uterine placental perfusion. A report of propofol infusion in two pregnant women undergoing prolonged neurosurgery describes the development of acidosis, as an atypical propofol infusion syndrome23. In general, safety data on the use of drugs by pregnant women are very poor. The vast majority of drugs currently on the market have never been studied in pregnant women in the pre-licensing trials. On the contrary, any safety data comes from the epidemiological surveillance of medicines after their release on the market. It is worth noting that even for dose titration or drug efficacy, conclusions are drawn by contact, from studies in men or non-pregnant women. Phase I studies for precautionary reasons, while the pharmaceutical companies themselves do not show much interest in this population group, both for commercial and legal reasons. Let’s see what conclusions we can come to by looking at the best data so far for the above in our topic through the table above (table 2)24-32.
Conclusions
The Intensive Care Unit of the Nicosia General Hospital in Cyprus, is the unit that receives all intubated patients with covid-19 from all over Cyprus, as well as pregnant intubated patients with covid – 19. In addition, we provide details about the obstetric treatment. of the women. Our study is constrained by the small sample size, which excluded us from presenting aggregate estimates.
With regard to COVID-19, the incidence of complications for women during pregnancy appears to be equivalent to the general population. Around 85% of pregnant women will have mild symptoms, 10% will have moderate symptoms and 5% are expected to be seriously ill. Research data today indicate that pregnant women with COVID-19 have an increased risk of miscarriage, premature birth, preeclampsia and caesarean section, especially when hospitalized for pneumonia24. Newborns are at high risk of endometrial death, respiratory failure and admission to the Neonatal Intensive Care Unit25.
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