Pregnant Patients in the ICU
While many pregnant women with COVID-19 have been able to recover at home or in community hospitals, the most seriously ill are usually transferred to UMMC because it has the highest level of intensive care for both baby and mother.
In the first year of the pandemic, hundreds of pregnant patients from around the state needed to at least consult with UMMC specialists, and dozens of these mothers who had COVID-related complications were sick enough that they needed to be transferred to UMMC from other hospitals.
Coordination More Important Than Ever
Overall, pregnant women who have COVID-19 are six times more likely to need to be hospitalized, compared to nonpregnant women with the disease. The good news, however, is that pregnant patients don't appear to have a higher risk of dying from COVID, compared to all COVID patients, said Sarah Crimmins, DO, medical director of the Obstetric Care Unit at UMMC and assistant professor of obstetrics, gynecology and reproductive sciences at the University of Maryland School of Medicine.
"What we've learned is that there needs to be a multidisciplinary approach to each and every one of these patients, because they all require complex care coordination," Crimmins said.
The most seriously ill pregnant COVID patients are cared for in UMMC's Medical Intensive Care Unit (MICU), while newborns who need special care are taken to the Neonatal Intensive Care Unit (NICU).
Early on, the obstetrics and neonatal teams set up space in the MICU for their highly specialized equipment for premature infants.
"If the delivery is a scheduled procedure, we try to take them to the operating room. But, you know, obstetrics is unpredictable," Crimmins said. "Sometimes we have to deliver them in the ICU."
"From the ICU team to the OB team, to at times the obstetric anesthesiology team, and also the NICU team – we are all critically involved," Crimmins said. "The other team that we have come to rely heavily on is the infectious disease team, as we learned what is or is not safe to give in pregnancy with these new therapeutic modalities."
The information is still limited, because clinical trials usually exclude pregnant patients.
"We have tried to take into consideration how sick they are, and determine whether the risk of the unknown is greater than the risk of withholding these medications in these patients," Crimmins said. "So it really takes individualized care. Each patient is unique. Each patient's disease process is different."
The medical community found that proning – positioning patients face down to allow the lungs to more fully inflate – helped COVID patients in the ICU who were on breathing tubes. In any patient, proning takes a team and special technique to deal with the equipment, monitors and safety of the patient.
"We had to modify the techniques to get pregnant patients in prone position, for obvious reasons," Crimmins said. "The baby is right where you lay them on their stomach."
Post-traumatic stress is a risk for some of these mothers who were so sick they needed a breathing tube before and after the baby was delivered, and who weren't even aware they had delivered the baby until they recovered. It's not the kind of birth experience mothers hope for.
"There have also been restrictions about visiting the baby in the NICU if the mothers are COVID-positive," Crimmins said. "Some mothers had to stay in the ICU for days or weeks after their delivery, and miss that early newborn period with their baby."
Mothers with COVID who were transported to UMMC were mostly there because of the chance that the baby would need to be delivered early due to the mother's illness. Most community hospitals don't have a NICU. UMMC has one of the state's largest NICUs and provides the highest level of intensive care available for newborns, while maternal specialists can address the cardiac, vascular and pulmonary issues the mother might face.
Nurses Manage Crises, Offer Comfort
"Our nursing staff has really stepped up," said Nicole Sweeney, BSN, RN, a labor-and-delivery nurse at UMMC, who has cared for mothers who were in the ICU and unable to have a family member with them.
In addition to their clinical excellence, she said, "We've supported these women and been there for them when family members can't be there."
Sweeney and other labor nurses must alternate between the Obstetric Unit and the MICU to care for their patients wherever they need to be. One pregnant patient in the MICU needed Sweeney to help her have a video call with her son.
"She was intubated but awake. I was helping her with the iPads we have in the hospital, so her son could talk to her from home. She couldn't talk to him because she was intubated. It was very emotional. I could see the pain in her eyes, having her son see her this way, but he seemed very happy to be able to see her.
"She ended up being OK, but it just really touched me, and I remember thinking, what is going on in this world right now? Like, how is this happening?" Sweeney said.
"There was an emergency delivery of another COVID patient where we had to deliver her baby in the room," Sweeney said, pausing as her emotions rose. The patient didn't speak English, and nurses were doing their best to calm her while also acting quickly to save her and the baby, as her oxygen levels dropped quickly.
"We ended up having to do an emergency C-section in her room to deliver a 28-week baby because it was super emergent," Sweeney said. "Anyway, it worked out. I used what I had, and the NICU team arrived in time and the baby ended up being OK. But these are things I never thought I would see in my career."