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Clinical course of severe and critical COVID-19 in hospitalized pregnancies: a US cohort study

Our take —

This study of 64 pregnant women with severe and critical COVID-19 in the US from May 2020, provides evidence that their disease course was similar to that reported among nonpregnant populations. Half of women with severe disease were discharged by 6 days after hospitalization, and half of women with critical disease were discharged by 10.5 days. The majority of deliveries during hospitalization were induced due to maternal condition, and 59% occurred preterm; there were only 2 cases of spontaneous preterm labor in this population. No women died; additionally, there were no neonatal deaths or stillbirths, and only one neonate tested positive for SARS-CoV-2 infection. However, follow-up was substantially incomplete, and the sample size was small. Subsequent studies have confirmed very low rates of neonatal infections in diverse settings, and though data remains limited and inconclusive on whether pregnancy confers independent risk for COVID-19 disease severity, the evidence to date indicates that death and poor obstetric outcomes are extremely rare for pregnant women with severe or critical COVID-19.

Study design

Case Series

Study population and setting

This study considered 64 pregnant women (mean age 33 years), hospitalized in 12 U.S. institutions (in New York City, Philadelphia, New Jersey, and Ohio) with laboratory-confirmed SARS-CoV-2 infection and severe or critical COVID-19, from March 5 to April 20, 2020. Critical disease was defined by a requirement of mechanical ventilation, septic shock, or multiple organ dysfunction/failure. The outcome of interest was the duration between hospital admission and discharge. A range of secondary outcomes were reported, including preterm delivery, the clinical course of COVID-19, concentrations of serum biomarkers, and various adverse outcomes.

Summary of Main Findings

Of the 64 women included, 20 (31%) had critical disease and 44 (69%) had severe disease. Twenty-one (31%) were Hispanic, 18 (28%) were non-Hispanic Black, and 16 (25%) were non-Hispanic white. One quarter of women had a pre-existing pulmonary condition, 17% had pre-existing cardiac disease, and the average BMI was 34. The mean gestational age at COVID-19 symptom onset was 29.9 weeks. All women with critical disease had symptom onset at a gestational age greater than 24 weeks. Most women (81%) were treated with hydroxychloroquine (81%); 25% were treated with remdesivir (25%). All women with critical disease were treated with anticoagulants. No maternal deaths occurred; one woman experienced cardiac arrest. In the critical group, 70% of women had acute respiratory distress syndrome (ARDS). The median duration of hospitalization was 6.0 days in the severe group and 10.5 days (sometimes reported by the authors as 12) in the critical group. Half of the women delivered during hospitalization: of these, 69% did so due to maternal condition, 9% due to fetal status, and 22% for obstetrical indication. Among women with critical disease, 15/20 (75%) delivered preterm; two women had spontaneous preterm labor. The route of delivery was cesarean for 53% of women with severe disease and for 94% of women with critical disease. There were no stillbirths or neonatal deaths; one neonate tested positive for SARS-CoV-2 infection at 48 hours of life but had no symptoms. ICU admission was required for 64% of neonates.

Study Strengths

Clinical outcomes and their timing were well-characterized.

Limitations

Follow-up was incomplete; 13 women remained hospitalized at the time of analysis, and 50% of women had not given birth. Longer-term outcomes were similarly not assessed. Only women with severe and critical disease were included; outcomes among women with mild or asymptomatic SARS-CoV-2 infection were not considered. No comparison was made with non-pregnant women of similar age, preventing inference about whether pregnancy confers additional risks in the context of severe COVID-19. Finally, the size of the study population was large relative to other studies of pregnant women with COVID-19 at the time of publication, but was too small to draw definitive conclusions about maternal and neonatal outcomes.

Value added

At the time of publication in May 2020, this was the largest study of severe and critical COVID-19 among pregnant women.

This review was posted on: 22 January 2021