Journal Pre-proof

From the Trenches: Inpatient Management of COVID-19 in Pregnancy

Marisa Vega, MD, Francine Hughes, MD, Peter S. Bernstein, MD, MPH, Dena
Goffman, MD, Jean-Ju Sheen, MD, Janice J. Aubey, MD, Noelia Zork, MD, Lisa
Nathan, MD, MPH

PII: S2589-9333(20)30098-7
DOI: https://doi.org/10.1016/j.ajogmf.2020.100154
Reference: AJOGMF 100154

To appear in: American Journal of Obstetrics & Gynecology MFM

Received Date: 28 April 2020

Revised Date: 25 May 2020
Accepted Date: 1 June 2020

Please cite this article as: Vega M, Hughes F, Bernstein PS, Goffman D, Sheen J-J, Aubey JJ, Zork N,
Nathan L, From the Trenches: Inpatient Management of COVID-19 in Pregnancy, American Journal of
Obstetrics & Gynecology MFM (2020), doi: https://doi.org/10.1016/j.ajogmf.2020.100154.

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© 2020 Published by Elsevier Inc.

 From the Trenches: Inpatient Management of COVID-19 in Pregnancy

Marisa Vega, MD,1 Francine Hughes, MD, 1 Peter S. Bernstein, MD, MPH, 1 Dena Goffman, MD,2

Jean-Ju Sheen, MD, 2 Janice J. Aubey, MD,3 Noelia Zork, MD, 2 Lisa Nathan, MD, MPH1

(1) Montefiore Medical Center/Albert Einstein College of Medicine, Department of Obstetrics &

Gynecology and Women's Health, Bronx, NY 10461

(2) Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia

University Medical Center, New York Presbyterian Hospital, New York, New York

(3) Department of Obstetrics and Gynecology, Columbia University Medical Center, New York

Presbyterian Hospital, New York, New York

Disclosure: The authors report no conflict of interest. This study received no financial support.

Corresponding author:

Lisa Nathan, MD, MPH

Jack D. Weiler Hospital/Montefiore Medical Center

1601 Tenbroeck Ave

Bronx, NY 10461

Email: lnathan@montefiore.org

Tel: 718-904-2767

Word count: Abstract: 126 Main Text: 3698

Marisa Vega, MD – conceptualization, writing – original draft

Francine Hughes, MD – conceptualization, writing – original draft

Peter S. Bernstein, MD, MPH – writing – review and editing

Dena Goffman, MD – writing – review and editing

Jean-Ju Sheen, MD – writing – review and editing

Janice J. Aubey, MD – writing – review and editing

Noelia Zork, MD – writing – review and editing

Lisa Nathan, MD, MPH- conceptualization, writing – original draft, supervision

 1

1 Condensation:

2 A practical guide for testing, admission criteria, and inpatient medical management of patients

3 with COVID-19, as well as tips for antepartum service management.

5 Short Title:

6 Inpatient Management of COVID-19 in Pregnancy

8 Keywords: Infectious disease in pregnancy; critical care in pregnancy; critical care obstetrics
 2

9 ABSTRACT

10 The novel coronavirus disease 2019 caused by the severe acute respiratory syndrome

11 coronavirus 2 has become a pandemic. It has quickly swept across the globe leaving many

12 clinicians to care for infected patients with limited information about the disease and best

13 practices for care. Our goal is to share our experiences of caring for pregnant and postpartum

14 women with novel coronavirus disease 2019 (COVID-19) in New York, the COVID-19 epicenter

15 in the United States and review current guidelines. We offer a guide, focusing on inpatient

16 management, including testing policies, admission criteria, medical management, care for the

17 decompensating patient, as well as practical tips for inpatient antepartum service management.

18

19 Key Words: COVID-19 in pregnancy, management of COVID-19, coronavirus disease in

20 pregnancy
 3

21 INTRODUCTION

22 The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread dramatically

23 around the world, but there has been little evidence-based data to guide clinical management

24 of patients with coronavirus disease 2019 (COVID-19), and even less on the management of

25 obstetric patients. It is known that the spectrum of disease attributed to COVID-19 is wide

26 including asymptomatic infection, mild upper respiratory disease, pneumonia, severe

27 respiratory distress, and death.1 Common presenting symptoms include fever, dry cough,

28 dyspnea, chest pain/tightness, fatigue, and myalgias. Less commonly, pregnant women may

29 report headache, confusion, rhinorrhea, sore throat, hemoptysis, vomiting, and diarrhea.1

30 Anosmia or ageusia with COVID-19 has also been reported. The incubation period from

31 exposure to symptom onset is 4-5 days, with a range of 2-14 days.1,2

32 Initial data suggests that pregnant women are not more susceptible to SARS-CoV-2 infection

33 than nonpregnant patients. Physiologic and anatomic changes associated with pregnancy,

34 however, may predispose patients to an increased risk for respiratory failure.3 Patients with co-

35 morbidities, such as asthma or other chronic lung disease, cardiovascular disease, hypertension,

36 HIV or other immunocompromised patients, body mass index >40, pre-gestational diabetes,

37 chronic kidney disease, and liver disease may have more significant adverse outcomes,

38 compared with other healthy pregnant women.1 Similar to maternal outcomes, there is limited

39 information on fetal and pregnancy outcomes in women with COVID-19. Previous data from

40 SARS and Middle East Respiratory Syndrome (MERS) pandemics illustrated an increase in

41 miscarriage, stillbirth, preterm and/or small for gestational age infants.1 Data is currently being

42 collected to determine if COVID-19 infection demonstrates similar trends. It should also be

 4

43 noted that high fevers, a common symptom of COVID-19, during the first trimester of

44 pregnancy can increase the risk of certain birth defects.1

45

46 This manuscript is meant to bring together guidelines from governmental and professional

47 organizations, as well as from the authors’ clinical experiences. The recommendations provided

48 below are evidence-based where possible, however much of it is derived from the authors’

49 clinical experience, as well as recommendations from infection control experts. It is also

50 important to note that guidelines are in constant flux as we learn more about SARS-CoV-2 and

51 its clinical manifestations. It is recommended that those taking care of COVID-19 patients

52 frequently refer to the updates provided by the Centers for Disease Control (CDC), the World

53 Health Organization (WHO), the Society for Maternal Fetal Medicine (SMFM), and the American

54 College of Obstetrics and Gynecology (ACOG) websites for the most current recommendations.

55

56 TESTING

57 First-line testing is performed using SARS-CoV-2 RT PCR with a nasopharyngeal swab. The test

58 has a high specificity and moderate sensitivity (60-80%)4. Swabbing of the nasopharynx is the

59 preferred choice for swab-based testing due to increased detection rates.1

60

61 The CDC currently recommends that clinicians use their judgment to determine whether a

62 patient should be tested.1 In our experience, universal testing of patients and partners has

63 helped identify asymptomatic carriers, likely limiting the spread of the virus and minimizing

64 exposure to staff and other patients. Women may present for admission with routine

65 obstetrical complaints and subsequently develop symptoms of COVID-19 during their

 5

66 hospitalization. Thus, consideration should be given for universal testing of patients admitted to

67 labor and delivery units5,6 based on the prevalence of the disease in the local community7 and

68 institutional resource availability.

69

70 Resource limitations including test availability and result time may be prohibitive, in which case

71 clinical judgement should be used. An alternative to universal testing includes utilizing

72 intentionally broad screening criteria and testing all patients that have COVID-19-related

73 symptoms, are febrile (temperature >100.0-100.4), or have epidemiologic risk factors (Table 1).

74 Symptoms of COVID-19 overlap with those of influenza and other viral respiratory diseases,

75 thus concomitant testing for these infections may be considered in some circumstances.

76 Anecdotal experience has also shown that consideration could be given to test patients on a

77 case-by-case basis who have an intrapartum or postpartum fever, suspected preeclampsia with

78 severe features, and HELLP syndrome due to overlap with COVID-19 features.

79

80 Variable laboratory turnaround times for SARS-CoV-2 test results needs to be taken into

81 consideration when constructing testing protocols. With rapid testing becoming increasingly

82 available, one should consider using this test for mildly ill or asymptomatic patients. However,

83 some laboratories have longer turnaround times. For those patients with a high clinical

84 suspicion for COVID-19, it may be prudent to treat them as such while awaiting test results. For

85 patients with a high clinical suspicion for COVID-19 and no obvious alternative diagnosis, but a

86 negative SARS-CoV-2 test result, continuation of isolation precautions is prudent and repeat

87 testing may be considered. This is due to the relatively high false negative rate of around 30%.4

88
 6

89 INPATIENT MANAGEMENT

90 Admission

91 All patients who present to the hospital should be screened for SARS-CoV-2 infection (Table 1).
92 As per recently published SMFM guidelines, admission to the hospital may be prudent for
93 pregnant women who test positive for COVID-19 and have moderate to severe symptoms
94 (tachypnea, dyspnea, refractory fever, oxygen saturation <95%), clinical findings suggestive of
95 more significant disease (pneumonia, abnormal blood gas), findings warranting pharmacologic
96 treatment and/or have comorbid conditions that increase risk of a more severe clinical course
97 (Table 2).8 In addition, those who do not have the ability to self-isolate at home, e.g.
98 undomiciled patients, may also be considered for admission.1 Patients meeting any admission
99 criteria may need intensive monitoring and should be considered for admission for a minimum
100 of 24-48 hours to determine the severity of their current status and potential for disease
101 progression. The degree of hypoxemia based on oxygen saturation levels has been used in
102 many algorithms to determine whether a non-pregnant patient should be admitted for
103 supportive care and observation or discharged home. The thresholds used for non-pregnant
104 adults, however, are not appropriate during pregnancy given the oxygen requirements of the
105 fetus necessitates a maternal oxygen saturation of >95%.3
106

107 All patients admitted to the hospital should have basic labs and imaging performed during their

108 initial evaluation (Table 3). Upon admission, confirm contact and droplet isolation precautions

109 have been transferred to the patient’s in-patient room (Table 4). For patients with hypoxia

110 (SpO2 <95%), check D-dimer, procalcitonin, ferritin, lactate dehydrogenase (LDH), and troponin

111 levels (Table 5). If the clinical presentation is concerning for bacterial superinfection, consider

112 obtaining a sputum culture and/or blood culture. Monitor fluid status, with hourly evaluation of

113 intake and output, and avoid volume overload. Conduct multidisciplinary discussions with

114 representation from obstetrics, anesthesiology, pediatrics, and nursing to plan for the next
 7

115 steps in patient management. Practical tips for antepartum service management can be found

116 in Table 6.

117

118 Laboratory/Imaging Findings

119 The vast majority of what is known about SARS-CoV-2 infection is derived from the general

120 population. Specific information relating to pregnant women is limited and the following must

121 be considered with caution.

122

123 Lymphopenia is common in patients infected with SARS-CoV-2 and has been reported in up to

124 83% of cases in non-pregnant individuals.1 In non-pregnant patients, greater illness severity has

125 been associated with severe lymphopenia, neutrophilia, elevated liver enzymes (ALT and AST),

126 elevated LDH, C-reactive protein (CRP), and ferritin.1 In general, critically ill patients have high

127 plasma levels of inflammatory markers, suggesting that immune dysregulation may play an

128 important role in disease severity and progression. Procalcitonin may be normal on admission,

129 but has been noted to be increased in COVID-19 patients, particularly among those requiring

130 admission to the ICU.1 It is important to note that markers of inflammation like CRP can be

131 mildly elevated during normal pregnancy (Table 7).5 Anecdotally, we have noted that CRP levels

132 >10mg/L have correlated with more significant disease and tends to increase/decrease with

133 worsening/improvement of the disease course. However, there are currently no reference

134 levels related to CRP and COVID-19 infection in pregnancy in the literature.

135
 8

136 The following laboratory findings that have been shown to be poor prognostic factors in the

137 general population include elevated CRP, elevated procalcitonin, thrombocytopenia (platelets

138 <100,000), and laboratory evidence of disseminated intravascular coagulation (DIC).9-11

139

140 Findings on chest x-ray suggestive of COVID-19 include bilateral air space consolidation and

141 bilateral or multilobular infiltrates.1 The appearance is often noted to have patchy reticular or

142 reticulonodular opacities. However, x-ray findings may be minimal in early disease and often lag

143 behind the clinical findings.1

144

145 CT scan findings typically include bilateral, peripheral ground glass opacities.1 Currently, the

146 American College of Radiology does not recommend CT scan for screening or first-line testing in

147 the diagnosis of COVID-19.12 Though CT scan may be indicated to evaluate for pulmonary

148 embolism, if indicated by clinical presentation, as symptoms can mimic COVID-19 related

149 respiratory symptoms and severe illness can increase risk of venous thromboembolism.

150

151 Medical Management

152 Pregnant women admitted to the hospital with known or suspected COVID-19 should be

153 monitored for signs of worsening respiratory distress or complications of the disease. These

154 include pneumonia, hypoxemic respiratory failure/ARDS, sepsis and septic shock,

155 cardiomyopathy and arrhythmia, acute kidney injury, and complications from prolonged

156 hospitalization, such as bacterial superinfections and venous thromboembolisms. It is worth

157 noting that worsening of symptoms may occur 6-10 days after the onset of symptoms.1

158
 9

159 Medical care is largely focused on infection prevention and control measures and supportive

160 care. Several medical therapies have been proposed to aid in the treatment of COVID-19 illness

161 including hydroxychloroquine, remdesivir, IL-6 inhibitors, and convalescent plasma. Though

162 multiple clinical trials are investigating the safety and efficacy of these treatments, currently

163 none have been approved by the U.S. Food and Drug Administration (FDA). Continuous review

164 of the literature is needed given rapidly changing guidelines and consultation with infectious

165 disease specialists may be warranted prior to initiation of medical management.

166

167 Based on promising data from in-vitro studies and one small non-randomized clinical study,

168 chloroquine or hydroxychloroquine13-15 quickly became first-line therapy for many hospitalized

169 patients with COVID-19, despite the lack of high quality data proving its efficacy in humans. Its

170 use can be considered based on institutional guidelines and consultation with infectious disease

171 specialists. Hydroxychloroquine is most commonly used in pregnancy for the treatment of

172 maternal lupus and is used outside of pregnancy to primarily treat rheumatoid arthritis,

173 systemic lupus erythematosus, and malaria. Although it can be detected in cord blood and

174 breast milk 16, no human studies have shown adverse fetal effects.17 Hydroxychloroquine is

175 generally considered safe in pregnancy and during breast feeding.

176

177 Prolonged QT syndrome may be a side effect of hydroxychloroquine. It should be used with

178 caution in patients with hepatic or renal dysfunction or when used in combination with other

179 drugs that may prolong QT intervals due to increased risk of arrhythmia. Prior to treatment

180 with hydroxychloroquine, a baseline EKG should be obtained to assess the QT interval and

181 treatment should not be initiated if the QTc is greater than 500. The package insert for
 10

182 hydroxychloroquine suggests an increased risk of hemolytic anemia in G6PD deficient

183 patients.18 Consideration should be given to G6PD testing but testing should not delay initiation

184 of treatment. Optimal dosing and duration of hydroxychloroquine for treatment of COVID-19

185 are unknown. Anecdotal dosing options are: 400 to 600mg orally every 12 hours for 24 hours,

186 followed by 400mg orally every 24hrs for 4-5 days.1

187

188 Other treatments under investigation include remdesivir, IL-6 inhibitors, and convalescent

189 plasma. Recently the FDA issued an emergency use authorization for Remdesivir, an

190 investigational antiviral medication, for inpatient treatment of patients with severe COVID-19

191 illness.19 Per the CDC, to date there is insufficient data to recommend the use of covalescent

192 plasma or IL-6 inhibitors though clinical trials are ongoing.1

193

194 Corticosteroids Use

195 Corticosteroid use in the setting of COVID-19 should be approached cautiously. The CDC

196 currently states that steroid use should be avoided unless indicated for other reasons, such as

197 asthma or reactive airway disease, chronic obstructive pulmonary disease, fetal lung maturity

198 promotion, or refractory septic shock. This recommendation is due to the potential of

199 corticosteroids to prolong viral replication, which has been observed with MERS, coronavirus,

200 and influenza infections.1 The Infectious Disease Society of America also suggests against the

201 use of steroids for patients admitted to the hospital with COVID-19 pneumonia. They however

202 recognize a potential benefit for patients who progress to ARDS due to COVID-19, in the

203 context of a clinical trial.20

204
 11

205 In pregnant women with a history of asthma, inhaled corticosteroids are preferred for mild to

206 moderate symptoms, along with an inhaled beta agonist when indicated. Metered-dose

207 inhalers (MDI) are preferred over nebulized treatments, which can aerosolize viral particles and

208 increase viral spread. Institutions may want to prioritize nebulized treatments for non-COVID-

209 19 patients with asthma to ensure availability of inhalers for COVID-19 patients. If a patient

210 requires a nebulizer treatment, then airborne precautions must be taken. Should inhaled

211 steroids fail to resolve symptoms, systemic corticosteroids may be administrated to SARS-CoV-2

212 infected pregnant women with asthma if necessary.

213

214 Antenatal corticosteroids for fetal lung maturity may be considered for pregnant women with

215 suspected or confirmed COVID-19 who are between 24 0/7 weeks and 33 6/7 weeks gestation

216 and at risk of preterm birth within 7 days. The theoretical risk of prolonged maternal infection

217 and potential decompensation after systemic steroids needs to be weighed against the

218 potential fetal benefit. ACOG does not recommend offering antenatal corticosteroids to

219 pregnant patients with suspected or confirmed COVID-19 who are beyond 34 0/7 weeks

220 gestation.21

221

222 Antibiotics for Bacterial Pneumonia

223 Antibiotics for bacterial pneumonia are generally not indicated when the clinical findings are

224 consistent with viral pneumonia. However, antibiotics may be warranted in setting of atypical

225 chest x-ray findings (e.g., a single area of consolidation), risk factors for aspiration, or risk

226 factors for superimposed bacteria pneumonia. Sputum cultures, blood cultures, and elevated

227 procalcitonin may be helpful in the diagnosis of superimposed bacterial pneumonia.

 12

228 Additionally, initiation of antibiotic treatment may have a role when clinical suspicion and/or

229 disease severity is high (e.g. prolonged intubation). Clinical judgement based on patient

230 presentation along with consideration for the safety profile in pregnancy should be used in the

231 selection of antibiotic type.

232

233 Anticoagulation

234 Coagulopathy and disseminated intravascular coagulation (DIC) resulting in microvascular

235 thrombosis and coagulation factor consumption have been seen in non-pregnant patients with

236 COVID-19. Laboratory values may demonstrate low platelets, prolonged prothrombin time (PT),

237 elevated D-dimer, and low fibrinogen levels, which may mimic HELLP syndrome and

238 preeclampsia with severe features. Over 70% of non-pregnant patients with fatal COVID-19

239 disease met criteria for DIC, compared to less than 1% in patients with non-fatal disease.22 The

240 International Society of Thrombosis and Haemostasis (ISTH) recommends measuring D-dimer

241 levels, PT, and platelet count in all patients with confirmed or suspected COVID-19.23 While

242 abnormal coagulation profiles are common in COVID-19 patients, bleeding has not been a

243 major finding. Therefore, some have recommended using D-dimer while others use the overall

244 clinical picture to determine anticoagulation approach.

245

246 If using D-dimer approach, prophylactic anticoagulation has been recommended for those with

247 D-dimer < 3.0 ug/mL and therapeutic anticoagulation for those with D-dimer >3.0 ug/mL9 in

248 non-pregnant patients. D-dimer levels are increased in pregnancy, particularly in the third

249 trimester (Table 7). In non-pregnant women, D-dimer ranges from 0.22-0.74 mcg/mL while in

250 the third trimester, levels range from 0.13-1.7 mcg/mL.24 The threshold for the level of D-dimer
 13

251 that should raise concern in pregnancy is not known, but consideration of prophylactic or

252 therapeutic anticoagulation based on the given clinical circumstances is critical, if no

253 contraindication exists (e.g. active bleeding or severe thrombocytopenia). This may be most

254 relevant for symptomatic patients, particularly those with thrombocytopenia and/or an

255 abnormal coagulation profile. It should be noted that abnormal PT or PTT is not a

256 contraindication to anticoagulation, and the full clinical picture should be taken into account.

257

258 While admitted to the hospital, venous thromboembolism (VTE) prophylaxis for COVID-19

259 pregnant women should be universally employed when delivery is not imminent. The decision

260 for therapeutic anticoagulation is considered on a case by case basis based on disease severity

261 and clinical parameters. In pregnancy, the timing of delivery and the risk for intrapartum

262 hemorrhage must be considered.

263

264 Finally, the duration for anticoagulation due to COVID-19 in pregnancy and the postpartum

265 period is not known. Given the well-known procoagulant state in the postpartum period, some

266 institutions have initiated anticoagulation up to 4-6 weeks in the postpartum period for some

267 high-risk women. Clinical judgement is necessary given lack of data driven protocols.

268

269 DELIVERY

270 Timing of Delivery

271 A diagnosis of COVID-19 alone is not an indication for delivery.21,25 In cases where women

272 recover from COVID-19 and have no other medical indications for delivery, it is reasonable to
 14

273 postpone delivery until quarantine status is lifted, to avoid transmission to the neonate.21

274 Delivery after this period should be for usual obstetric indications.

275

276 Delivery timing in the preterm patient with acute respiratory distress poses unique challenges

277 and care should be individualized. Given that the risks of prematurity after 34 weeks of

278 gestation are typically minimal, the threshold for delivery may be lower than that at less than

279 34 weeks of gestation, particularly in the setting of acute respiratory distress and/or significant

280 co-morbidities that may increase the risk of maternal decompensation. In patients 24 0/7 to 33

281 6/7 weeks gestation, prolonging pregnancy for fetal benefit needs to be weighed against the

282 maternal risk of decompensation. The lack of clear evidence that evacuation of the uterus will

283 improve maternal respiratory function in women with acute respiratory failure from COVID-19

284 pneumonia complicates decision-making. In the setting of worsening maternal respiratory

285 status and potential for deterioration, an interdisciplinary discussion should be held between

286 obstetrics, anesthesiology, pulmonary/critical care, pediatrics and nursing, together with the

287 patient and her family.25

288

289 Mode of Delivery

290 Diagnosis with COVID-19 alone is not an indication for cesarean section.21 In cases where the

291 risk of respiratory decompensation appears low, it is reasonable to allow spontaneous labor or

292 attempt induction of labor to achieve a vaginal delivery if no other contraindications exist. An

293 assisted second stage may be necessary if the patient has severe dyspnea and/or hypoxia with

294 valsalva. A simple walk test can provide helpful information on the patient’s exercise tolerance

295 prior to induction of labor. For moderate-to-severe cases of respiratory distress, the risks
 15

296 associated with surgery need to be balanced against the risk of respiratory decompensation in

297 labor.

298

299 It is prudent to avoid intubation if clinically possible, both due to the risk of aerosolization, as

300 well as the inherent increased risks of intubation in the pregnant state. Pregnancy is associated

301 with increased upper airway edema and rapid oxygen desaturation that is worsened with

302 COVID-19 respiratory distress. Thus, we recommend early epidural anesthesia when

303 appropriate to minimize the need for general anesthesia in the event of an emergent cesarean

304 delivery.26

305

306 Vertical Transmission and Fetal Effects

307 Currently, case reports suggest that vertical transmission may occur, however, the rate of

308 vertical infection and the clinical impact on the fetus or newborn are not clear.27 Nor is it clear

309 whether the transmission to the newborns occurred antenatally, during the delivery, or as a

310 result of neonatal exposure. Vertical transmission has not been reported for MERS & SARS.1

311 Consideration should be taken to send all placentas from COVID-19 positive mothers to

312 pathology for evaluation. This will add an additional source of information regarding vertical

313 transmission and how the virus may affect pregnancy.

314

315 To date, no evidence of teratogenic effects of COVID-19 has been shown. However, there

316 currently is no data to inform possible long-term teratogenic effects as SARS-CoV-2 has only

317 been present since December 2019. Of note, one case report described a fetal demise in the

318 setting of a critically ill mother with COVID-19.28

 16

319

320 ACUTE DECOMPENSATION

321 Oxygenation Goals

322 The fetus requires a maternal PaO2 greater than 70 mm Hg for sufficient oxygenation. Maternal

323 hypoxia and hypocapnia results in fetoplacental vasoconstriction which is poorly tolerated by

324 the fetus. Thus maternal oxygenation goals include SpO2 of 95% or higher or PaO2 of 70 mm Hg

325 or higher.3 Electronic fetal monitoring may be useful as a maternal vital sign and a continuous

326 indication of maternal oxygenation status. Fetal monitoring should also be utilized when fetal

327 intervention, including delivery, would be considered.8

328

329 Intubation and Mechanical Ventilation

330 Intubation should be a multidisciplinary and individualized decision. Indications for intubation

331 include apnea, inability of the patient to protect her airway, PaO2 less than 70 mmHg on

332 supplemental oxygen of higher than 50%, elevated and rising PaCO2 (for reference values see

333 Table 7), increased work of breathing, mental status deterioration, and hemodynamic

334 instability.29

335

336 Intubation carries a significant risk due to the physiologic changes of pregnancy. Endotracheal

337 intubation when necessary should be performed in as controlled an environment as possible.

338 Increased rates of intubation failure in pregnancy are due to upper airway edema and

339 hyperemia, and rapid oxygen desaturation following apnea.30 There is also an increased risk of

340 aspiration due to reduced tonus of the lower esophageal sphincter, increased abdominal

341 pressure, and delayed gastric emptying.3

 17

342

343 Due to the decreased oxygen reserve in pregnancy, secondary to decreased functional residual

344 capacity and increased oxygen consumption, intubation should be performed with 100% O2

345 preoxygenation, with rapid sequence induction (without ventilation via a face mask), and with

346 cricoid pressure.3 Given the risk of aerosolization of the virus, intubation should ideally be

347 performed in a negative pressure room and all providers should be donned in appropriate PPE

348 including n95 mask.

349

350 Mechanical ventilation settings in pregnancy should include higher peak inspiratory pressure

351 and positive end expiratory pressure (PEEP). Hyperventilation should be avoided to prevent

352 subsequent respiratory alkalosis which can induce decreased uterine blood flow.3,29 PaCO2

353 should not be lower than 30 mm Hg (normal physiologic range of pregnancy is 30-32 mmHg).

354 Tidal volumes should be initiated at 4 ml to 6 ml/kg of lean body weight.3 Treatment of ARDS in

355 pregnancy follows the same guidelines as in non-pregnant patients: lung-protective ventilation,

356 anti-infectious medications, and supportive therapy.3,31

357

358 Cardiopulmonary Failure

359 Several physiologic and anatomic changes in pregnancy make the pregnant patient susceptible

360 to cardiopulmonary failure.3 These include increased cardiac demands due to increased cardiac

361 output, the mechanical effects of the gravid uterus, and the increased metabolic demands of

362 pregnancy.

363
 18

364 Patients with COVID-19 should be monitored for signs of cardiac dysfunction and pulmonary

365 edema. If there is a concern, an echocardiogram should be performed to assess left ventricular

366 function. The treatment of pulmonary edema includes supplementation with oxygen and

367 diuretics, along with inotropic agents and pressure support to maintain MAP >65 in the setting

368 of cardiac failure.

369

370 POSTPARTUM MANAGEMENT

371 Delivery does not always improve the pregnant COVID-19 patient’s respiratory status and acute

372 respiratory decompensation remains a risk in the postpartum period. Supportive care remains

373 the mainstay of management with continuation of any medical management initiated

374 antenatally or intrapartum. Additionally, consideration of anticoagulation in the severely ill

375 patients is warranted.8 A duration of 4-6 week could be considered given known heightened

376 thrombotic risk.

377

378 Nonsteroidal anti-inflammatory drugs (NSAIDs)

379 It has been hypothesized that NSAIDs may worsen COVID-19 disease as they cause increased

380 ACE-2 expression and coronavirus binds cells through the ACE-2 receptor.32 However, clinical

381 data thus far have not validated this theory. SMFM, ACOG, and the FDA have not restricted

382 NSAID use with COVID-19 patients.21,33,34 We recommend that women who are asymptomatic

383 or mildly symptomatic can continue to use NSAIDs as needed. However, it is reasonable to

384 avoid NSAIDs in severely symptomatic patients given the theoretical risk.33

385

386 Breastfeeding
 19

387 COVID-19 infection is not a contraindication to breastfeeding.25,35 Studies to date have not

388 detected coronavirus in breast milk. Breastfeeding should be encouraged as it likely provides

389 antibodies against coronavirus for the infant. Mothers who wish to directly breastfeed should

390 wear a mask, perform strict hand hygiene, and wash their breasts with soap and water prior to

391 feeding1 to avoid neonatal acquisition via respiratory droplets. Alternatively, mothers may use a

392 breast pump and a healthy caregiver can bottle feed the infant until the mother is no longer

393 quarantined. All components of the breast pump must be cleaned thoroughly between

394 pumping sessions.

395

396 DISCHARGE AND FOLLOW-UP

397 Clinical recovery has been correlated with the detection of IgM and IgG antibodies suggesting

398 immunity, however there is limited data on the possibility of reinfection.1

399

400 Ongoing transmission appears to occur up to approximately 7 days following the initial

401 presentation of symptoms. Thus, appropriate counseling about quarantining the patient and

402 her contacts should be provided based on CDC recommendations. Briefly, after 72 hours

403 afebrile without the use of fever-reducing medication and improvement in symptoms and at

404 least 7 days have passed since symptoms first appeared, isolation can be discontinued.1 After

405 the isolation period, patients should continue to practice proper hygiene protocols and avoid

406 contact with vulnerable persons.

407

408 Similar to the pregnant COVID-19 patient, postpartum patients with COVID-19 may also initially

409 be stable or improving and later develop worsening symptoms. Consideration should therefore
 20

410 be given to discharging the postpartum patient with a pulse oximeter and clear parameters to

411 trigger either a call to a provider or a return to the hospital. A list of postpartum COVID-19

412 patients should also be maintained. The patients should be contacted regularly via telephone

413 call, text, or video to provide patient education and identify patients needing physician

414 evaluation and/or hospital admission. This should be continued until complete resolution of the

415 patient’s signs and symptoms of infection.

416

417 Conclusion:

418 The speed of the emergence and spread of COVID-19 around the world has placed an incredible

419 strain on healthcare staff and resources, particularly in the field of obstetrics. The key to

420 responding to this crisis is thoughtful, standardized, and evidence-based care whenever

421 possible. Contained in this article are suggestions for management. As more evidence

422 accumulates, guidance will inevitably change.

 21

423 Figure and Table Legend

424 Table 1: Checklist for COVID-19 Screening. Alternative screening checklist when resources are

425 not available for universal screening.

426

427 Table 2: Admission Criteria for COVID-19 Pregnant Women and Patients under Investigation

428 (PUIs). Suggested admission criteria for pregnant women. If the patient meets any of the

429 following criteria, admission should be considered on a case-by-case basis taking into account

430 the full clinical picture.

431

432 Table 3: Checklist for initial management and evaluation of PUIs for COVID-19. Initial

433 management and suggested admission order set, including laboratory and imaging, for newly

434 admitted patients.

435

436 Table 4: COVID-19 in Pregnancy Management after Admission Checklist. Order set and

437 supportive care medical checklist.

438

439 Table 5: Tip Sheet: Hypoxia in COVID-19 Pregnant Patients. Checklist for pregnant women with

440 hypoxia and acute decompensation (defined as rapidly increasing supplemental oxygen need in

441 order to maintain O2 >95%).

442
 22

443 Table 6: Antepartum Service Management Tips. Tips for improving efficiency and decreasing

444 staff exposure during COVID-19 pandemic.

445

446 Table 7: Reference Ranges for Common COVID-19 Laboratory Tests

447
 23

448 References

449 1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19).
450 https://www.coronavirus.gov/. Published 2020. Accessed 4/30/20.
451 2. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-
452 19) and Pregnancy: What obstetricians need to know. Am J Obstet Gynecol. 2020;222(5):415-
453 426.
454 3. Schwaiberger D, Karcz M, Menk M, Papadakos PJ, Dantoni SE. Respiratory Failure and
455 Mechanical Ventilation in the Pregnant Patient. Crit Care Clin. 2016;32(1):85-95.
456 4. Loeffelholz MJ, Tang YW. Laboratory diagnosis of emerging human coronavirus infections - the
457 state of the art. Emerg Microbes Infect. 2020;9(1):747-756.
458 5. Vintzileos WS MJ, Hoffmann E, Vo D, John NS, Vertichio R, Vintzileos AM. Screening all pregnant
459 women admitted to Labor and Delivery for the virus responsible for COVID-19. American Journal
460 of Obstetrics and Gynecology. 2020; doi: https://doi.org/10.1016/j.ajog.2020.04.024.
461 6. Breslin N BC, Gyamfi-Bannerman C, et al. Coronavirus disease 2019 infection among
462 asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an
463 affiliated pair of New York City hospitals. Am J Obstet Gynecol MFM. 2020; doi:
464 10.1016/j.ajogmf.2020.100118
465 7. Breslin N BC, Miller R, Fuchs K, Goffman D, Gyamfi-Bannerman C, D’Alton M. COVID-19 in
466 pregnancy: early lessons. American Journal of Obstetrics & Gynecology MFM. 2020; doi:
467 https://doi.org/10.1016/j.ajogmf.2020.100111.
468 8. The Society for Maternal-Fetal Medicine. Management Considerations for Pregnant Patients
469 With COVID-19.
470 https://s3.amazonaws.com/cdn.smfm.org/media/2336/SMFM_COVID_Management_of_COVID
471 _pos_preg_patients_4-30-20_final.pdf. Published April 30, 2020. Accessed 5/10/20.
472 9. Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based
473 on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020;46(5):846-
474 848.
475 10. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J
476 Med. 2020;382(18):1708-1720.
477 11. Lippi G, Plebani M. Procalcitonin in patients with severe coronavirus disease 2019 (COVID-19): A
478 meta-analysis. Clin Chim Acta. 2020;505:190-191.
479 12. The American College of Radiology. ACR Recommendations for the use of Chest Radiography
480 and Computed Tomography (CT) for Suspected COVID-19 Infection.
481 https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-
482 for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection. Published March 22, 2020.
483 Accessed 5/13/20.
484 13. Yao X, Ye F, Zhang M, et al. In Vitro Antiviral Activity and Projection of Optimized Dosing Design
485 of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2
486 (SARS-CoV-2). Clin Infect Dis. 2020; doi: https://doi.org/10.1093/cid/ciaa237
487 14. Liu J, Cao R, Xu M, et al. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in
488 inhibiting SARS-CoV-2 infection in vitro. Cell Discov. 2020;6:16.
489 15. Gautret P, Lagier JC, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of
490 COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020;
491 doi: https://doi.org/10.1016/j.ijantimicag.2020.105949.
492 16. Costedoat-Chalumeau N, Amoura Z, Aymard G, et al. Evidence of transplacental passage of
493 hydroxychloroquine in humans. Arthritis Rheum. 2002;46(4):1123-1124.
494 17. Osadchy A, Ratnapalan T, Koren G. Ocular toxicity in children exposed in utero to antimalarial
495 drugs: review of the literature. J Rheumatol. 2011;38(12):2504-2508.
 24

496 18. Mohammad S, Clowse MEB, Eudy AM, Criscione-Schreiber LG. Examination of
497 Hydroxychloroquine Use and Hemolytic Anemia in G6PDH-Deficient Patients. Arthritis Care Res
498 (Hoboken). 2018;70(3):481-485.
499 19. U.S. Food and Drug Administration. Coronavirus (COVID-19) Update: FDA Issues Emergency Use
500 Authorization for Potential COVID-19 Treatment. https://www.fda.gov/news-events/press-
501 announcements/coronavirus-covid-19-update-fda-issues-emergency-use-authorization-
502 potential-covid-19-treatment. Published May 1, 2020. Accessed 5/15/20.
503 20. Infectious Diseases Society of America. Infectious Diseases Society of America Guidelines on the
504 Treatment and Management of Patients with COVID-19. https://www.idsociety.org/practice-
505 guideline/covid-19-guideline-treatment-and-management/. Published April 21, 2020. Accessed
506 5/14/20.
507 21. American College of Obstetricians and Gynecologists. COVID-19 FAQs for Obstetrician-
508 Gynecologists, Obstetrics. https://www.acog.org/clinical-information/physician-faqs/covid-19-
509 faqs-for-ob-gyns-obstetrics. Published 2020. Accessed 4/30/20.
510 22. Tang N BH, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased
511 mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost.
512 2020;18(5):1094-1099.
513 23. Thachil J TN, Gando S, Falanga A, Cattaneo M, Levi M, Clark C, Iba T. ISTH interim guidance on
514 recognition and management of coagulopathy in COVID-19. J Thromb Haemost.
515 2020;18(5):1023-1026.
516 24. Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and laboratory studies: a reference
517 table for clinicians. Obstet Gynecol. 2009;114(6):1326-1331.
518 25. The Society for Maternal-Fetal Medicine. Coronavirus (COVID-19) and Pregnancy: What
519 Maternal-Fetal Medicine Subspecialists Need to Know.
520 https://s3.amazonaws.com/cdn.smfm.org/media/2317/COVID19-
521 What_MFMs_need_to_know_revision_4-11-20_(final)_PDF.pdf. Published 2020. Accessed
522 4/30/20.
523 26. Boelig RC MT, Oliver EA, Di Mascio D, Saccone G, Bellussi F, Berghella V. Labor and Delivery
524 Guidance for COVID-19. American Journal of Obstetrics & Gynecology MFM. 2020; doi:
525 https://doi.org/10.1016/j.ajogmf.2020.100110.
526 27. Zimmermann P, Curtis N. COVID-19 in Children, Pregnancy and Neonates: A Review of
527 Epidemiologic and Clinical Features. Pediatr Infect Dis J. 2020;39(6):469-477.
528 28. Zaigham M, Andersson O. Maternal and Perinatal Outcomes with COVID-19: a systematic review
529 of 108 pregnancies. Acta Obstet Gynecol Scand. 2020; doi: https://doi.org/10.1111/aogs.13867.
530 29. Deblieux PM, Summer WR. Acute respiratory failure in pregnancy. Clin Obstet Gynecol.
531 1996;39(1):143-152.
532 30. Lapinsky SE. Management of Acute Respiratory Failure in Pregnancy. Semin Respir Crit Care
533 Med. 2017;38(2):201-207.
534 31. ARDSnet. NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary.
535 http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf. Accessed 5/17/20.
536 32. Wan Y, Shang J, Graham R, Baric RS, Li F. Receptor Recognition by the Novel Coronavirus from
537 Wuhan: an Analysis Based on Decade-Long Structural Studies of SARS Coronavirus. J Virol.
538 2020;94(7).
539 33. Society for Maternal-Fetal Medicine and Society for Obstetric and Anesthesia and Perinatology.
540 Labor and Delivery COVID-19 Considerations.
541 https://s3.amazonaws.com/cdn.smfm.org/media/2319/SMFM-
542 SOAP_COVID_LD_Considerations_-_revision_4-14-20_PDF_(003).pdf. Published 2020. Accessed
543 4/30/20.
 25

544 34. Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory
545 drugs (NSAIDs) for COVID-19. https://www.fda.gov/drugs/drug-safety-and-availability/fda-
546 advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19. Published 2020.
547 Accessed 4/30/20.
548 35. American College of Obstetricians and Gynecologists. Novel Coronavirus 2019 (COVID-19)
549 Practice Advisory. https://www.acog.org/clinical/clinical-guidance/practice-
550 advisory/articles/2020/03/novel-coronavirus-2019. Published March 2020 Accessed 4/30/20.

551
Table 5: Tip Sheet: Hypoxia in COVID-19 Pregnant Patients

SUPPLEMENTAL OXYGEN (amount of oxygen delivered by each modality is modifiable and

can be adjusted to patient’s needs): (goal O2 > 95%)

NC 2-9L NRB 10-15L

move to a negative pressure room

High Flow NC CPAP Intubation ECMO

ACUTE DECOMPENSATION: (modify based on severity)

Consider repeating baseline admission labs (CBC, BMP, LFTs, magnesium, phosphate,

PT, PTT, Fibrinogen, CRP, LDH, D-dimer)

Add Procalcitonin

Assess for signs of cardiac injury: troponin, BNP, consider echo

Assess acid base status

Continuous fetal monitoring as a 6th “vital sign”

Monitor hourly intake/output

Assess for bacterial superinfection (repeat CXR, sputum culture, and/or blood culture)

Left lateral vs prone positioning as tolerated

ANTENATAL CORTICOSTEROIDS:

• Weigh risk of potential worsening respiratory status versus potential fetal benefit

• Consider if 24 0/7 to 33 6/7 weeks and preterm delivery anticipated within 7 days

• Do not recommend if >34 weeks

DELIVERY:
 • Multidisciplinary and individualized decision

• <34wks

o maternal risk of decompensation needs to be weighed against fetal benefit of

prolonging pregnancy

• >34wks

o consider delivery if acute respiratory distress despite supportive care and/or

presence of significant co-morbidities increasing risk of decompensation

NC=nasal cannula, NRB=nonrebreather mask, CPAP=Continuous positive airway pressure, ECMO=

Extracorporeal membrane oxygenation

Table 6: Antepartum Service Management Tips

Antepartum Service Management Tips:

• Create a contact list of key consultants and administration liaisons (nursing

administration, neonatology, infectious disease, critical care, pulmonology)

• Round efficiently:

o Avoid pre-rounding by house staff to decrease healthcare worker exposure

o See patients in the following order:

1. SARS-CoV-2 negative patients and COVID-19 screen negative patients

2. Patients under investigation for COVID-19

3. Confirmed COVID-19 patients

This is to decrease chance of transmission and help conserve personal

protective equipment (PPE) as needed

o Utilize in-room media to aid rounding, for example:

- One person outside of the patient room is stationed at a computer to check

lab results, write notes, and enter orders while on speaker phone with the

team in the room

- The provider stationed at a computer keeps the team in the room informed

of pertinent details as handoff sheets and other reference materials cannot

be easily or safely accessed when in full PPE in the patient’s room

• Obtain ambulatory pulse oximetry measurements (walk test) for stable patients as part

of the physical exam - patients may appear deceptively well without exertion
• Pocket ultrasounds for biophysical profiles may be useful for COVID-19 patients as an

alternative to nonstress tests to limit the number of providers entering the room
Table 7: Reference Ranges for Common COVID-19 Laboratory Tests

Second Third
Laboratory Test Nonpregnant First Trimester Trimester Trimester
3 3
WBC (x10 /mm ) 3.5-9.1 5.7-13.6 5.6-14.8 5.9-16.9
9
Platelet (x10 /L) 165-415 174-391 155-409 146-429
D-Dimer (µg/mL) 0.22-0.74 0.05-0.95 0.32-1.29 0.13-1.7
Ferritin (ng/mL) 10-150 6-130 2-230 0-116
CRP (mg/L) 0.2-3.0 Not reported 0.4-20.3 0.4-8.1
Procalcitonin (µg/mL) 0.01-0.15 0.018-0.051 0.018-0.051 0.02-0.15
Fibrinogen (mg/dL) 233-496 244-510 291-538 373-619
PT (sec) 12.7-15.4 9.7-13.5 9.5-13.4 9.6-12.9
PTT (sec) 26.3-39.4 24.3-38.9 24.2-38.1 24.7-35.0
INR 0.9-1.04 0.89-1.05 0.85-0.97 0.08-0.94
AST (U/L) 12-38 3-23 3-33 4-32
ALT (U/L) 7-41 3-30 2-33 2-25
LDH (U/L) 115-221 78-433 80-447 82-524
Magnesium (mg/dL) 1.5-2.3 1.6-2.2 1.5-2.2 1.1-2.2
Phosphate (mg/dL) 2.5-4.3 3.1-4.6 2.5-4.6 2.8-4.6
Troponin I (ng/mL) 0.08 Not reported Not reported 0-0.064
Creatine kinase (U/L) 39-238 27-83 25-75 13-101
BNP (pg/mL) <167 Not reported 13.5-29.5 Not reported
pH (venous) 7.31-7.41 7.36-7.52 7.40-7.52 7.41-7.53
pO2 (mmHg) 90-100 93-100 90-98 92-107
pCO2 (mmHg) 38-42 Not reported Not reported 25-33
-
HCO3 (mEq/L) 22-26 Not reported Not reported 16-22

1. Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and laboratory studies: a reference table for

clinicians. Obstet Gynecol. 2009;114(6):1326-1331.

2. Hu Y, Yang M, Zhou Y, Ding Y, Xiang Z, Yu L. Establishment of reference intervals for procalcitonin in healthy

pregnant women of Chinese population. Clin Biochem. 2017;50(3):150-154

Table 2: Admission criteria for COVID-19 pregnant women and Patients Under Investigation

Suggested Admission Criteria

CLINICAL

• Severe shortness of breath

• Tachypnea (>20 breaths per minute)

• Hypoxia (O2 saturation <95% on room air with ambulation)

• Pneumonia on imaging

• Severe asthma

• Serious co-morbidities (e.g. cancer, HIV infection, Type I diabetes mellitus)

LABORATORY

• Elevated C-reactive protein

• Elevated procalcitonin

• Platelets <100,000

• Elevated prothrombin time

• D-dimer >3 ug/mL

• Elevated liver function tests

(PUIs)
Table 3: Checklist for initial management and evaluation of PUIs for COVID-19

Nurse dons appropriate PPE (mask, isolation gown, face shield/goggles, and gloves)

Nurse places a mask on patient and visitor

Nurse escorts patient to private room (does not need to be negative pressure) and door is

kept closed at all times

Place droplet and contact isolation notifications on the door

Place isolation cart with PPE outside the door

Minimize number of staff who enter the room—only one doctor and one nurse should

evaluate and provide care to the patient

Order the following labs:

CBC, with differential

Basic metabolic panel

Liver function tests

Magnesium

Phosphorous

PT, PTT, fibrinogen, D-Dimer

CRP

Respiratory pathogen test—send one or multiple of the following per your

hospital’s guidelines:

SARS-CoV-2 test

Influenza

Respiratory pathogen panel

Order Chest X-Ray (CDC recommends portable to reduce exposure risk)

Table 1: Checklist for COVID-19 screening

SCREENING*

Step 1: Ask each patient and visitor the following questions. “Yes” to any question = POSITIVE

screen

Have you been diagnosed with COVID-19?

Have you been exposed to someone with known or suspected COVID-19 in the last 14

days?

Have you recently had, or do you currently have any one of the following?
Subjective or measured fever (>100.0)
Chills
Cough
Shortness of breath
Sore throat
Diarrhea
Malaise/Myalgia
Headache
Congestion/runny nose
Loss of taste
Loss of smell
Step 2: Measure temperature. A temperature ≥ 100.0°F = POSITIVE screen

Take the temperature of all patients who present to the hospital at entry if possible

and/or at presentation to triage or labor and delivery units, as well as their support

person
*If your institution has the resources, consider sending a test for SARS-CoV-2 infection on all

patients who present to the triage or labor and delivery units

Table 4: COVID-19 in Pregnancy Management after Admission Checklist

ORDERS

Contact and droplet isolation (airborne isolation if patient requires high flow NC or

nebulizers)

Vital Signs: if stable obtain every 4 hours at minimum, if unstable consider continuous

monitoring

Fetal monitoring: at least once daily NST as appropriate

Admission labs: CBC, BMP, LFTs, Magnesium, Phosphorous, PT, PTT, Fibrinogen, D-

dimer, CRP

Daily Labs: CBC, BMP, LFTs, Magnesium, Phosphorus

Every Other Day Labs: CRP, LDH, D-Dimer

Anticoagulation & Sequential Compression Devices

SUPPORTIVE CARE

Supplemental oxygen to maintain a saturation > 95%

Antipyretics

Avoid fluid overload

o if the patient requires continuous infusion try to keep it <75cc/hr

o if septic or hemodynamically unstable give fluids per protocol

MEDICAL MANAGEMENT
Consider initiating if the patient has one of the following:

Requires supplemental oxygen

Has significant work of breathing

Severe co-morbidities

Given rapidly changing guidelines, consideration should be based on institutional guidelines

and consultation with infectious disease specialists