Parturient with COVID-19 and need for intensive care: an observational study in the Nordic countries.

OBJECTIVE

Patients with COVID-19 who need intensive care have severe respiratory insufficiency and a greatly increased hemostatic function, with a risk of thromboembolic complications. The physiological changes in pregnancy result in increased demands on respiration and circulation alongside an already activated hemostatic function. Thus, the care of pregnant patients with severe COVID-19 may be particularly challenging. Our objectives were to present the clinical picture of such patients in Scandinavia from April 2020 to August 2020 and describe their course of care while in the intensive care unit (ICU).

STUDY DESIGN

The Swedish Ethical Review Authority approved this study (reference number 2020-02678; approved on June 25, 2020). Written informed consent was not required according to the Authority and was thus not obtained in all cases.

Between April 2020 and August 2020, members of the Swedish Association for Obstetric Anesthesia and Intensive Care and all participants in the Scandinavian Society of Anesthesia & Intensive Care obstetrical anesthesia training program were invited to complete questionnaires in an ongoing manner if they cared for a pregnant woman admitted to the ICU because of COVID-19. Obstetrical anesthesiologists from 34 hospitals agreed to participate (n=6 Danish, n=5 Finnish, n=6 Norwegian, and n=17 Swedish hospitals). The questionnaire variables included the medical history, pregnancy and delivery status, anesthesia, intensive care indication, organ function, and outcome. Information about the country of origin was requested retrospectively.

The questionnaire responses are presented descriptively as means (or median) ± standard deviation, minimum and maximum for continuous variables, and number and percentage for categorical variables. The observations not provided (herein called “missing”) were excluded from the analyses.

Results

Eleven hospitals returned questionnaires regarding 21 patients in total (86% from Sweden). Their ages ranged from 21 to 39 years (mean, 30 years), and 14 patients were born outside their country of residence (missing for n=6; Table 1 ). Most women had preexisting comorbidities (81.0%): almost half (47.6%) were obese (body mass index >30), 23.8% had diabetes, and 19.0% had hypothyroidism. Six (33.3%) women were regularly using medication, including 5 who were taking ≥2 medications (27.8%). Most women were multiparous (61.9%).

Table 1

Study population characteristics of 21 pregnant patients treated for COVID-19 in the intensive care unit in Sweden, Finland, and Denmark.

Variables	Descriptive statistics	Total n per variable (number of missing data)
Age in y, mean (SD), (range)	30.0 (5.5), (21.0–39.0)
Foreign country of origin, n, %	14, 93.3	15 (6)
COVID-19 symptoms, n, %	21, 100.0	21 (0)
BMI, mean (SD), (range)	31.3 (8.0), (19.2–55.0)	21 (0)
Preexisting comorbidities
Obesity (BMI>30), n, %	10, 47.6	21 (0)
Diabetes, n, %	5, 23.8	21 (0)
Pulmonary disease, n, %	1, 4.8	21 (0)
Hypertension, n, %	0, 0.0	20 (1)
Hypothyroidism, n, %	4, 19.0	21 (0)
Othera, n, %	5, 25.0	20 (1)
None reported, n, %	4, 19.0	21 (0)
Medicationsb, n, %	6, 33.3	18 (3)
0 medications, n, %	12, 66.7	18 (3)
1 medication, n, %	1, 5.6	18 (3)
2 medications, n, %	2, 11.1	18 (3)
3 medications, n, %	3, 16.7	18 (3)
Number of pregnanciesc, median (SD), (range)	2.0 (1.6), (1.0–7.0)	21 (0)
Multiparous, n, %	13, 61.9	21 (0)
Nulliparous, n, %	8, 38.1	21 (0)
Pregnancy complicationsd, n, %	0, 0.0	18 (3)
Gestational age in wk in ICU admission, mean (SD), (range)	31.3 (5.5), (22.0–40.0)	16 (5)

Data are presented as mean or median (SD) and (range), or percent of total number per variable (excluding missing data).

BMI, body mass index; SD, standard deviation.

Including, eg, Protein S deficiency, schizophrenia

Indicating whether the patient was on any medication, including budesonide, desloratadine, olanzapine, duroferon, folic acid or iron polysaccharide, omeprazole, levetiracetam, insulin or insulin analogs, and levothyroxine

Including the current pregnancy

Including, eg, preeclampsia, thromboembolism, bleeding, premature delivery, and stillbirth.

The most commonly reported COVID-19 symptoms were dyspnea (95.2%), fever (66.7%), cough (57.1%), and tachycardia (57.1%); women most frequently presented with multiple symptoms. Four women received both prepartum and postpartum ICU care (26.7%). All the patients survived, and most had delivered their baby at the time of discharge from the ICU (76.2%).

Fifteen patients required a ventilator (71.4%), including 6 via tracheotomy, whereas 2 received extracorporeal membrane oxygenation (ECMO; Table 2 ). One patient who received ECMO support suffered a cardiac arrest. The time on the ventilator ranged from 1.5 to 56.0 days (mean, 16.5 days). Three women required dialysis (17.6%). In addition, 13 women received sedatives and 16 received anticoagulants (missing for n=5).

Table 2

Intensive care unit therapy characteristics for entire study population (N=21) and obstetrical outcomes of a subset of the study population who gave birth while in the intensive care unit (n=16).

Variables	Descriptive statistics	Total n per variable (number of missing data)
ICU therapy characteristics
Reason for admission to ICU
Respiratory failure, n, %	20, 95.2	21 (0)
Another cause, n, %	1, 4.8	21 (0)
Total care time in d, mean (SD), (range)	25.2 (27.8), (3.0–94.0)	21 (0)
Total time in ICU in d, mean (SD), (range)	14.7 (16.8), (0.5–61.0))	21 (0)
Use of ventilator, n, %	15, 71.4	21 (0)
Tracheotomy, n, %	6, 40.0	15 (8)
Extracorporeal membrane oxygenation, n, %	2, 13.3	15 (8)
Time on ventilator in d, mean (SD), (range)	16.5 (16.4), (1.5–56.0)	15 (0)
Dialysis, n, %	3, 17.6	17 (4)
Medication
Sedatives, n, %	13, 81.3	16 (5)
Anticoagulants, n, %	16, 100.0	16 (5)
Status at discharge from ICU
Alive, n, %	21, 100.0	21 (0)
Dead, n, %	0, 0.0	21 (0)
Delivered, n, %	16, 76.2	21 (0)
Not delivered, n, %	5, 23.	21 (0)
Obstetrical outcomes
Time of delivery in wk, mean (SD), (range)	32.7 (5.1), (25.0–41.0)	16 (0)
Indication for delivery
Maternal only, n, %	16, 100.0	16 (0)
Respiratory failure, n, %	14, 87.5	16 (0)
Fetal + maternal, n, %	2, 12.5	16 (0)
Cesarean delivery, n, %	16, 100.0	16 (0)
General anesthesia, n, %	8, 50.0	16 (0)
Spinal anesthesia, n, %	7, 43.8	16 (0)
Epidural top-up, n, %	1, 6.2	16 (0)
Postpartum bleeding mL per 24 h, mean (SD), (range)	620.0 (386.3), (200–1500)	15 (1)
Severe bleedinga, n, %	3, 20.0	15 (1)
Apgar score
At 1 min, mean (SD), (range)	6.9 (2.7), (2–10)	15 (1)
At 5 min, mean (SD), (range)	8.9 (1.8), (6–10)	15 (1)
At 10 min, mean (SD), (range)	9.6 (0.7), (8–10)	9 (4)

Data are presented as mean (SD) and (range) or percent of total n per variable (excluding missing data).

ICU, intensive care unit; SD, standard deviation.

Severe postpartum bleeding defined as blood loss of >1000 mL per 24 hours.

Five women (23.8%) were discharged from the ICU before delivery, and 4 (19.0%) delivered vaginally at full term; the mean weeks of pregnancy at ICU admission for these 5 women was 28.6 weeks. The delivery time for the remaining women ranged from 25 to 41 weeks (mean, 32.7±5.1 weeks). The primary indication for delivery was maternal for 16 women, of which 2 deliveries were also because of fetal indication. All 16 women delivered via cesarean delivery, and 3 women had severe postpartum bleeding (>1000 mL). Eight (50.0%) received general anesthesia, 7 (43.8%) received spinal anesthesia, and 1 (6.2%) received a top-up epidural. Three newborns were reported to be admitted to the neonatal ICU, including 1 because of the need for continuous positive airway pressure. However, this was not explicitly requested in the questionnaire and is thus underreported.

Conclusion

The women included in this study were critically ill with COVID-19 and required care in the ICU for an average of 14.7 days including serious respiratory support such as tracheostomy and ECMO. Interestingly, 5 patients recovered from COVID-19, were discharged from the ICU, and delivered their newborn at term (1 via elective cesarean delivery). All the patients survived.

Our results align with recent studies reporting high percentages of pregnant patients with obesity and severe COVID-19 requiring ICU care, and with those reporting high rates of births via cesarean delivery and preterm births for patients with severe COVID-19. , We observed longer hospitalization times than other reports.

One limitation of this study is that most of the included patients received care in Sweden, which may be partly explained by the high incidence of COVID-19 in Sweden at the time. Although the total patient number is limited, our results complement the published registry studies by focusing specifically on pregnant patients in ICUs in the Nordic countries.