Establish disease severity | Comments |
- NIH criteria for severe COVID-19 (any of the following):
- Sustained respiratory frequency >30 breaths per minute
- SpO2 <94% on room air at sea level
- Ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300
- Lung infiltrates >50%
- NIH criteria for critical COVID-19 (any of the following):
- Respiratory failure (acute respiratory distress syndrome)
- Septic shock
- Multiple organ dysfunction
| In pregnancy, the SpO2 goal is ≥95% on room air at sea level so values <95% trigger intervention for severe disease. |
Respiratory support | Comments |
- Options include:
- Low- or high-flow oxygen
- Prone position
- Noninvasive positive-pressure ventilation
- Mechanical ventilation
- Subsequent interventions include recruitment maneuvers and high PEEP strategies, neuromuscular blocking agents, pulmonary vasodilators, and ECMO as a last resort
| Escalate respiratory support as needed to achieve/maintain SpO2 ≥95%. By comparison, the typical SpO2 target in nonpregnant adults with COVID-19 who are receiving supplemental oxygen is 92 to 96%. If the prone position is utilized, pillows/padding are used to ensure no pressure is exerted on the gravid abdomen. Refer to UpToDate content on respiratory care of adult COVID-19 patients for detailed information. |
Medical management | Comments |
- Dexamethasone 6 mg orally or IV once daily for 10 days or until discharge, whichever is shorter.
| Dexamethasone is indicated for severely ill patients with COVID-19 who are on supplemental oxygen or ventilatory support. For patients who also meet criteria for use of antenatal corticosteroids to induce fetal maturity, administer dexamethasone 6 mg IV every 12 hours for 4 doses, followed by 6 mg orally or IV once daily for 8 days (10 days total duration), or until discharge, whichever is shorter. Refer to UpToDate content on management of hospitalized adults with COVID-19 for detailed information. |
| Refer to UpToDate content on management of hospitalized adults with COVID-19 for detailed information. |
- In selected patients, other therapeutics recommended for nonpregnant adults with severe/critical COVID-19 and which may be considered in pregnancy include baricitinib (a JAK inhibitor) and tocilizumab (interleukin-6 antagonist), but there is no or minimal information on fetal risks.
| Refer to UpToDate content on management of hospitalized adults with COVID-19 for detailed information. Decisions about use of JAK inhibitors and interleukin-6 antagonists during pregnancy should involve shared decision-making, considering potential maternal benefit and lack of information on fetal risks. |
- VTE prophylaxis:
- In pregnant patients in whom urgent delivery is likely: prophylactic or intermediate dose unfractionated heparin SUBQ
- In pregnant patients in whom urgent delivery is not likely: prophylactic or intermediate dose enoxaparin SUBQ
| Refer to UpToDate content on prevention of venous thromboembolism in pregnancy for detailed information on dosing. |
- Empiric treatment for influenza or bacterial pneumonia, when indicated.
| Refer to UpToDate content on management of hospitalized adults with COVID-19 for detailed information. |
Pregnancy evaluation | Comments |
- Obstetric ultrasound (eg, fetal number, fetal and placental position, gestational age, fetal weight, AFV)
- GBS culture in patients ≥23 weeks, begin penicillin G pending culture results for standard indications
- FHR monitoring:
- 14 to <23 weeks: FHR check daily
- ≥23 weeks: CTG at least daily
| Refer to UpToDate content on prevention of early-onset neonatal GBS for detailed information. The FHR monitor can be used continuously in severely ill hospitalized patients in whom emergency cesarean birth would be performed for a persistent nonreassuring fetal heart rate pattern. An abnormal tracing might also help guide maternal oxygen therapy. In patients with stable SpO2, a nonstress test can be performed once or twice daily, as one option. |
Timing of delivery | Comments |
- In general, if SpO2 ≥95% can be achieved, even if maximum respiratory support is required, the pregnancy can be continued.
- Decision-making regarding delivery at the patient level depends on many factors, including:
- The precise gestational age and plans for neonatal resuscitation.
- The severity of hypoxemia.
- The rate of disease progression and response to escalating therapy.
- Results of tests of fetal well-being.
- Comorbidities.
- For pregnancies between 23 and 34 weeks of gestation, whether a course of antenatal corticosteroids has been completed.
| Continue medical and obstetric care as long as the patient is stable or improving. Delivery is not always indicated. |
Route of delivery | Comments |
- In the absence of contraindications to vaginal birth, a trial of labor is attempted if SpO2 ≥95% can be achieved, even if maximum respiratory support is required.
- In patients >20 weeks of gestation who have a cardiac arrest, resuscitative cesarean delivery is advised.
- In patients with a fetal demise, the pregnancy is terminated by induction or by dilation and extraction, if a provider with the appropriate expertise is available.
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Management of undelivered, recovered patients | Comments |
- Fetal ultrasound:
- At 18 to 20 weeks, if not already performed, and
- At 32 weeks or 4 weeks after recovery (whichever occurs later in gestation)
- Routine prenatal care with delivery for standard obstetric indications.
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