Among women with COVID-19-related acute respiratory distress syndrome (ARDS) who were pregnant, elective cesarean delivery was found to be superior to expectant management only when there was an increased risk of intrauterine or maternal mortality. These study findings were published in the American Journal of Obstetrics & Gynecology MFM.

Researchers conducted a clinical decision analysis that assessed outcomes associated with elective delivery vs expectant management among women with COVID-19-related ARDS. Elective delivery was defined as immediate cesarean delivery, and expectant management was defined as the continuation of pregnancy until spontaneous delivery or decision to deliver. Outcomes assessed included long-term maternal functional impairment, cerebral palsy in infants, and mortality. The researchers built a parallel open-cohort simulation model that cycled daily to describe the dynamics of critical illness, delivery, and the subsequent course of both women and their neonates. The model outputs included hospital or perinatal survival, life expectancy, quality-adjusted life-years (QALYs), fetal loss, and gestational age at birth.

The base case for the analysis was a pregnant woman at 32 weeks’ gestation with a single living fetus, receiving invasive mechanical ventilation in an intensive care unit due to COVID-19-related ARDS. All patients included in the analysis were cared for at a tertiary hospital. All pregnancies were singleton with a live fetus and uncomplicated before COVID-19 infection onset, and all patients had received antenatal steroids for fetal lung maturation.

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In comparing elective delivery vs expectant management at 32 weeks’ gestation, the model outputs were similar in regard to the rate of maternal hospital survival (87.1% vs 87.4%), expected life-years (31.5 vs 31.6 years), and QALYs (29.7 vs 29.8 years). For women at 32 weeks’ gestation, expectant management was associated with an increased risk of perinatal mortality compared with elective delivery (3.5% vs 1.4%; difference, -2.2%; 95% CI, -3.5% to -0.8%). Of note, the estimated rate of maternal hospital survival and at-term delivery associated with expectant management was 72% (95% CI, 69-75).

For neonates, elective delivery at 32 weeks’ gestation was associated with a 5.2% increase in the rate of perinatal survival vs expectant management (98.4% vs 93.2%; 95% CI, 3.5-7.0). However, the estimated rates of long-term complications (0.7% vs 0.2%; difference, 0.4%; 95% CI, -0.2 to 1.0) and expected life-years (44.6 vs 43.2) among neonates were similar between elective delivery vs expectant management. Of note, expectant management was associated with an estimated mean gestational age at birth of 38 (range, 37.9-38.3) weeks.

This study was limited as the simulation model included only women without comorbidities who received antenatal steroids. In addition, pregnancy-related complications, such as preeclampsia, were not incorporated into the model.

The researchers recommend “… basing the decision for elective delivery versus expectant management in a pregnant individual with COVID-19-related ARDS on gestational age and likelihood of intrauterine or maternal death”.


Resende MF, Yarnell C, D’Souza R, et al. Clinical decision analysis of elective delivery versus expectant management for pregnant individuals with COVID-19-related acute respiratory distress syndrome. Am J Obstet Gynecol MFM. Published online July 22, 2022. doi:10.1016/j.ajogmf.2022.100697

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