At Brigham and Women’s Hospital, the Department of Obstetrics and Gynecology and Division of Maternal-Fetal Medicine have a long history of caring for patients with complex health conditions that affect pregnant women, including placenta accreta and heart disease.
“The Brigham’s rich history of caring for complicated pregnant patients prepared our teams for many of the challenges that the COVID-19 pandemic brought,” said Sarah Rae Easter, MD, an OB/GYN with specialty training in maternal-fetal medicine (MFM) and critical care medicine. “We already had playbooks for these high-risk pregnant patients. We just needed to adapt them to COVID-19.”
Since the beginning of the pandemic, obstetric providers at the Brigham have worked with multidisciplinary teams from labor and delivery, anesthesia and the intensive care unit (ICU) to develop protocols for managing critically ill pregnant patients with COVID-19. These guidelines were included in a paper co-authored by Dr. Easter in the American Journal of Perinatology.
Developing Protocols for COVID-Positive Pregnant Patients
In March of 2020, Dr. Easter was the attending intensivist for the first dedicated COVID-19 ICU at the Brigham. It gave her valuable time to understand what ICU teams needed in order to care for COVID-positive patients.
“Critically ill pregnant women were thankfully rare,” said Dr. Easter. “But each case brought opportunities to improve our care for COVID-positive pregnant women in the ICU. Even routine diagnoses presented unique challenges for this patient population. For example, how do you diagnose labor in an intubated, sedated and paralyzed patient with COVID-19?”
To assist ICU providers, the obstetrics team created guidelines for when the OB providers should be contacted. Their tips sheet for intensivists caring for critically-ill pregnant patients was placed outside the rooms of COVID-positive pregnant patients in the ICU. The obstetricians reviewed normal hemodynamic targets for pregnancy. Obstetric nurses taught their ICU nursing counterparts how to monitor for contractions and understand fetal heart rate tracing.
Dr. Easter and her colleagues developed a variety of detailed COVID-19 protocols to care for these COVID-positive pregnant women. These protocols are available to providers in the obstetrics section of the COVID Clinical Guidelines. They include: suggestions for communicating with the obstetrics team, an induction checklist for critically ill patients and cesarean delivery for COVID-positive patients.
The majority of these COVID-19 protocols were developed in multidisciplinary meetings. There, providers from multiple departments discussed complicated cases and determined care plans for these COVID-positive pregnant patients.
“Our multidisciplinary teams meet routinely to discuss complicated pregnant patients,” said Dr. Easter. “This highly collaborative approach to caring for sick pregnant patients was second nature to us. We just had to update our plans to address a new disease.”
Balancing Priorities for Critically-Ill Pregnant Patients
Layering a critical illness like COVID-19 on top of pregnancy’s physiologic demands adds many clinical concerns with competing priorities. Even simple questions like when and how to deliver the baby can become extraordinarily complex for pregnant patients with COVID-19.
“We know vaginal delivery is safer for mothers,” said Dr. Easter, “but an attempted vaginal birth with the potential need for an emergent cesarean delivery required a coordinated effort from everyone on the care team.”
In this regard, the team had to balance the health of mother and baby, the risk of developing blood clots from COVID-19 with the risk of bleeding at delivery, and the goal to avoid unnecessary surgery during labor and delivery.
“For one of our COVID-positive pregnant patients, it took about 20 providers and several hours to develop a delivery plan,” said Dr. Easter. “Our induction checklist could be used by providers from different specialties when they cared for pregnant patients in the COVID-19 ICU.”
In another case, the obstetrics team successfully proned a COVID-positive pregnant patient. The prone position improved oxygen supply to the patient’s lungs and resolved her refractory hypoxia. Dr. Easter described the method she and others used to prone this pregnant patient in their American Journal of Perinatology review paper.
Providing Expert Obstetrical Care During COVID-19
To practice their COVID-19 protocols, the obstetrics team led weekly simulations with providers from labor and delivery, anesthesia, nursing and the ICU. The most important simulation involved the transfer a COVID-positive pregnant patient from the ICU to an operating room in the event of an emergent cesarean delivery.
“The pandemic taught me that the complex obstetrical care the Brigham was already providing could be easily adapted to optimize care pregnant patients with COVID-19,” said Dr. Easter. “In this time of great uncertainty one thing has become clear to me: I’m incredibly fortunate to work with such a caring and competent group of providers.”