COVID

Question 1

What is COVID?

Answer 1

Corona Virus Disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Question 2

How does COVID-19 spread?

Answer 2

primarily spread through person-to-person contact via respiratory droplets, which are relatively heavy, fall from the air before evaporating, and are unlikely
to spread more than 6 feet

Question 3

What is known about COVID-19 disease severity in pregnancy?

Answer 3

• increased risk for severe disease (3-fold
  increased risk for both ICU admission and
  invasive ventilation)
• increased risk of extracorporeal membrane oxygenation (ECMO) (2.4-fold increased risk)
• 70% increased risk of death from COVID-19

Women with comorbidities and older
women appeared to have a particularly elevated risk of adverse maternal outcomes.

Women of color, specifically Latina or Black women, also continued to be disproportionately affected by severe maternal morbidity and mortality (although 14.1% of the total sample, they represented 36.6% of deaths overall, including 26.5% of deaths among pregnant women)

Question 4

Who should be tested for SARS-CoV2?

Answer 4

To decide which patients are tested for SARS-CoV2 use:

• Clinical judgment
• Test availability
• Community spread data

Question 5

What are the signs and symptoms of SARS-CoV2?

Answer 5

mild to severe and include fever
myalgias
cough
difficulty breathing
gastrointestinal symptoms
anosmia

Question 6

Is there evidence of in-utero transmission of COVID-19?

Answer 6

SARS-CoV-2 receptors used for cell entry are only minimally expressed within the human placenta.

In-utero transmission is less likely as a result

Question 7

Does COVID-19 cause miscarriage or congenital anomalies?

Answer 7

No increased risk of miscarriage.

No data on congenital anomalies.

Question 8

Are women infected with COVID-19 at increased risk for preterm birth and stillbirth?

Answer 8

Preterm birth has been reported but it is iatrogenic. a preterm delivery rate of 8.9%.

Increased risk for stillbirth in the pandemic however the patients are not known to have COVID. This could be due to decreased care because of the pandemic.
Stillbirth rate of 3.2%

Question 9

Should obstetric care appointments be altered because of COVID?

Answer 9

Where available, telehealth (including telephonic and other remote services) can be used to allow access to care for these patients while implementing community mitigation efforts

Question 10

Do women with COVID-19 need additional antenatal surveillance?

Answer 10

• Detailed anatomic scan
• Interval growth assessment
• Antenatal testing is reserved for routine obstetrical indications

Question 11

Are there delivery considerations for patients with COVID?

Answer 11

• For women infected early in pregnancy who recover, no alteration to the usual timing of delivery is necessary.
• For women infected at or near term, the timing of delivery should be individualized.
• For women who are critically ill, preterm delivery may be considered if it is thought that it could potentially improve maternal status.

Question 12

What protective measures can be taken for the neonate with a mother who has COVID?

Answer 12

Rooming-in with precautions has been endorsed by the American Academy of Pediatrics.

Question 13

What is considered a mild COVID-19 disease?

Answer 13

Mild disease is defined as:
-flu-like symptoms (fever, cough, myalgias,
anosmia)
-NO dyspnea, shortness of breath or abnormal chest imaging.

Question 14

What is considered a moderate COVID-19 disease?

Answer 14

Moderate disease is defined by:
- evidence of lower respiratory tract disease with
clinical assessment (dyspnea, pneumonia on imaging, abnormal blood gas, refractory fever of 102.2 °F or greater not alleviated with acetaminophen) while maintaining an oxygen saturation of greater than or equal to 94% on room air at sea level

Question 15

What is considered a severe COVID-19 disease?

Answer 15

Severe disease is defined by:

• a respiratory rate greater than 30
• hypoxia with oxygen saturation less than 94%
• a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen of less than 300 (P/F ratio)
• greater than 50% lung involvement on imaging

Question 16

What is considered a critical COVID-19 disease?

Answer 16

Critical disease is defined as multi-organ failure or dysfunction, shock, or respiratory failure requiring mechanical ventilation or high-flow nasal cannula

Question 17

What are inpatient criteria for COVID 19 infection in pregnancy?

Answer 17

• Pregnant COVID 19 with comorbid conditions
• Pregnant COVID 19 with moderate to severe disease
• Pregnant COVID 19 with fever greater than 39oC despite tylenol

Question 18

What is secondary hemophagocytic lymphohistiocytosis in COVID patients?

Answer 18

sHLH is a fulminant and often fatal hypercytokinemia associated with multi-organ failure. The disease is defined by unremitting fever, cytopenia, and high ferritin levels.

Question 19

What are reasons for evaluation in a patient that is managed outpatient for COVID-19?

Answer 19

○ Worsening shortness of breath
○ Tachypnea (30/min)
○ Unremitting fever (greater than 39 °C) despite appropriate use of acetaminophen
○ Inability to tolerate oral hydration or needed medications
○ Oxygen saturation less than 95% either at rest or on exertion (if home pulse oximetry available)
○ Persistent pleuritic chest pain
○ New-onset confusion or lethargy
○ Cyanotic lips, face, or fingertips
○ Obstetrical complaints, such as preterm contractions, vaginal bleeding, or decreased fetal movement

Question 20

What is the quick Sequential Organ Failure Assessment (qSOFA) score and how should it be used in evaluation of COVID patient?

Answer 20

qSOFA score can be used to assess inpatient admission.

3 clinical criteria:

• systolic blood pressure ≤100 mm Hg
• respiratory rate ≥22 per minute
• altered mental status

If 2 or more of these criteria are present then high risk for poor sepsis related outcomes

Question 21

What are the components of Sequential Organ Failure Assessment (SOFA) score?

Answer 21

• P/F ratio
• Platelet
• Bilirubin
• MAP
• Glasgow Coma Score
• Serum Creatinine

Question 22

What are criteria for intensivist consultation in COVID patient that is inpatient?

Answer 22

Presence of any of the following:
• Inability to maintain oxygen saturation ≥95% (pulse oximetry) with supplemental O2/rapidly escalating supplemental oxygen need.

• Hypotension (mean arterial pressure MAP <65) despite appropriate fluid resuscitation (~500-
1000 mL bolus of crystalloid fluids, eg, lactated Ringer’s solution).

• Evidence of new end-organ dysfunction (eg, altered mental status, renal insufficiency, hepatic
insufficiency, cardiac dysfunction, etc.

Question 23

When would you intubate a patient with COVID-19?

Answer 23

Greater than 15 L per minute (by common nasal cannula or mask)

Greater than 40 to 50 L per minute by high-flow nasal cannula

Greater than 60% fraction of inspired oxygen (FiO2) by Venturi mask to maintain an oxygen saturation of 95% or greater by transcutaneous pulse oximeter.

The inability of a patient to protect the airway due to altered mental status (Glasgow
coma scale of less than 8)

Question 24

What are alternatives to intubation for COVID-19 patient?

Answer 24

● Common nasal cannula (maximum of 15 L per minute deliverable)

● Face mask: “Non-rebreather” type; maximum dependent on source, typically up to
15 L per minute (LPM) from wall supply; may be increased to ~50 LPM with an additional source

● Venturi face mask: Supplies support via fraction of inspired oxygen (FiO2); maximum of 60% oxygen delivery

● Use of noninvasive positive-pressure ventilation, eg, bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP)

Question 25

What is extracoporeal membrane oxygenation?

Answer 25

Extracorporeal membrane oxygenation (ECMO) is used to artificially perform the function of the lungs (venovenous; VV ECMO) or the heart as well as the lungs (venoarterial; VA ECMO) in patients with severe ARDS that is refractory to other measures (outlined above), with or without concomitant cardiac dysfunction.

Question 26

What are the risks for extracoporeal membrane oxygenation?

Answer 26

stroke (10%)
hemorrhage (30%)
deep venous thrombosis (70%)
pulmonary embolism (16%)
limb ischemia (<5%)

Question 27

What are the treatments for COVID-19 in a hospitalized patient requiring oxygen therapy?

Answer 27

• Remdesivir
• Dexamethasone (6mg IV/day x 10 days) (if fetal lung maturity then 6mg IM q12 x 2 days then 6mg IV x 10 days)
• Monoclonal antibodies
• Antibiotics (Ceftriaxone and azithromycin)

Question 28

What is the benefit of procalcitonin level in the setting of COVID?

Answer 28

it can be used to help delineate superimposed bacterial pneumonia.
If less than 0.1 ng/mL then no pneumonia

Question 29

Suggested timing of delivery for COVID patients:

Answer 29

-if at or after 32 weeks of gestation with refractory hypoxemia

-Neonatal mortality is 0.2% at 32
weeks and remains at this level or lower for each week thereafter. Major morbidity occurs infrequently at these gestational ages as well: 8.7% at 32 weeks, 4.2% at 33,
4.4% at 34, 2.8% at 35, and 1.8% at 36 weeks of gestation.

If delivery is being considered and ECMO and pulmonary vasodilators are not available, transport should also be considered.