Proning modus operandi in pregnancies complicated by acute respiratory distress syndrome secondary to COVID-19

Abstract

Introduction

Prone positioning has been widely utilized in ARDS management before and during the COVID-19 pandemic due to its demonstrated mortality benefits. In pregnancy, proning requires careful attention to often overlooked physiologic changes in pregnancy and additional technical challenges accompanying a gravid abdomen. The purpose of this manuscript is to demonstrate a proning technique that was successfully used at our institution to avoid premature delivery of the fetus while improving maternal outcomes. All technical challenges are addressed in the instructional videos using a pregnant model with twin gestation at 32 weeks.

Methods

We reviewed all the patients’ charts with positive SARS-CoV-2 from March 2020 until July 2020 and identified those who developed ARDS. Subsequently, we identified four patients that were proned during the antepartum period. We described their clinical course, including the change in ventilatory parameters in relationship with proning timing. Stepwise instructions for self-proning and proning in mechanically ventilated patients are illustrated in video format.

Results

During the study period, we identified 100 pregnant patients with SARS-CoV-2 infection. Mechanical ventilation was required in 8 of these patients. In four cases, proning was performed during the antepartum period. We were able to improve the P/F ratio while decreasing FiO₂ and avoiding iatrogenic preterm delivery. Except for one case, where the patient self-extubated and required emergent delivery, all patients were successfully extubated, followed for prenatal care, and delivered for usual obstetric indications.

Conclusion

Proning remains a well-proven intervention in ARDS and should be considered in pregnant women when indicated. We recognize that proning might not be effective in all cases. However, proning positioning is an option to improve oxygenation in patients with severe hypoxemia when the next consideration is delivery of a premature infant or maternal cannulation for extracorporeal membrane oxygenation.

Keywords:

• ARDS
• COVID-19
• SARS-CoV-2
• prone position
• prone

Disclosure statement

No potential conflict of interest was reported by the author(s).

Authors contribution

Each author was involved in the writing and revising of the manuscript, read and approved the final version.

Proprietary Information

The videos, including any related images, proprietary data, information, and documentation made available to the Journal of Maternal, Fetal & Neonatal Medicine are the exclusive and confidential property of the University of Maryland Medical System Marketing and Communications Office. Any alterations to the video are not permitted.

Acknowledgments

We are grateful to Bill Seiler, Erin Rummel, Alexandra Bessent, Chris Wells, Kelly Kennedy, McLellan Shelby, Jessica Peterson, and Amanda Sullivan for assistance creating the proning video instructions.