Case of the Month #23 - obstetrics & SARS-CoV-2

The MBRRACE-UK report on maternal deaths normally compiles cases over a 3-year period in the UK. A rapid report on SARS-CoV-2 reviewed the deaths of 10 pregnant patients with coronavirus in the period March to May 2020 (8). 7 of the 10 women who died were from black, Asian, and minority ethnic groups.

MBRRACE describes much quicker recognition of viral symptoms and definitive diagnosis of infection compared to the 2009 H1N1 pandemic. However, it discussed a highly variable level of care provided thereafter. In particular, recognition and management of the deteriorating patient was delayed. Much of the ‘obstetric review was performed by junior staff, and after the women gave birth there was a scarcity of further obstetric and midwifery review’[8].

Where these sick women were cared for has been highlighted as a particular problem by MBRRACE. They were treated in areas of the hospital unable to manage their multiple problems. MBRRACE reinforces the need for leadership, the need for regular senior review and co-ordinated multi-disciplinary and specialist input which should be continued into the extended postpartum period.

In one case, when deterioration was recognised, an emergency caesarean section was then undertaken but by a junior member of obstetric staff and then the patient returned to the same inappropriate clinical area. Respiratory function improved shortly after delivery but then subsequently deteriorated 24 hours after.

RCOG have published criteria for recognising a deteriorating pregnant patient with COVID-19 (9); signs of decompensation include:

• FiO2>0.4 (titrated to keep SpO2>94%)
• Respiratory rate > 30/minutes
• Reduction in urine output
• Drowsiness
• (Even if oxygen saturations are normal)

Those women that did receive critical care, all did so in temporarily repurposed settings such as operating theatres or recovery areas. They were usually cared for by staff redeployed from different roles, who were both unfamiliar with critical care equipment and looking after a pregnant or post-partum patient. Critical care services must be aware of, and adhere to, the standards of care set out in GPICS version 2 (4.10) on care of the critically ill pregnant (or recently pregnant) woman and Care of the critically ill woman in childbirth: enhanced maternal care (10, 11).

Multiple triage areas were using general adult early warning scores which failed to pick up on a deteriorating obstetric patient. Modified Early Obstetric Warning Scores (MEOWS) are available, however were likely to have been in short supply in these emergency areas (12). There is likely to have been minimal training in the use of these scores in general acute medical and emergency areas.