Risk factors and outcomes of critically ill pregnant COVID-19 patients: Experience from the first and second waves of the pandemic

Associations of complications with admission to ICU

Complications		Admission		P value
		General ward (N= 94)	ICU (N= 19)
Acute kidney injury				0.003
	Yes	1 (20%)	4 (80%)
	No	93 (86.1%)	15 (13.9%)
Liver injury				<0.001
	Yes	0 (0%)	5 (100%)
	No	94 (87.0%)	14 (13.0%)
Sepsis				0.001
	Yes	0 (0%)	4 (100%)
	No	94 (86.2%)	15 (13.8%)
Gestational hypertension				0.033
	Yes	2 (40%)	3 (60%)
	No	92 (85.2%)	16 (14.8%)
Preeclampsia				0.526
	Yes	3 (75%)	1 (25%)
	No	91 (83.5%)	18 (16.5%)
Eclampsia				1.000
	Yes	1 (100%)	0 (0%)
	No	93 (83.0%)	19 (17.0%)

Hemodynamic status in the ICU

Variables		Outcomes		OR (95% CI)	P value
		Improvement (N = 11)	Death (N = 8)
Hemodynamic status
Arterial line inserted					0.633
	Yes	6 (50%)	6 (50%)	0.400 (0.055–2.933)
	No	5 (71.4%)	2 (28.6%)	1.000
Echocardiography (N = 13)
Dimension					1.000
	Abnormal	4 (44.4%)	5 (55.6%)	0.800 (0.076–8.474)
	Normal	2 (50%)	2 (50%)	1.000
Ejection fraction					1.000
	<55%	0 (0%)	1 (100%)	N/A
	≥55%	6 (50%)	6 (50%)	N/A
TAPSE (N=11)					N/A
	≤16	0	0
	>16	5 (45.5%)	6 (54.5%)
Diastolic dysfunction					1.000
	Yes	1 (33.3%)	2 (66.7%)	0.500 (0.034–7.452)
	No	5 (50%)	5 (50%)	1.000
Valve abnormality (N=12)					1.000
	Yes	4 (44.4%)	5 (55.6%)	0.800 (0.076–8.474)
	No	1 (33.3%)	2 (66.7%)	1.000
Pericardial effusion					1.000
	Yes	0 (0%)	1 (100%)	N/A
	No	6 (50%)	6 (50%)	N/A
Any vasopressor					0.003
	Yes	3 (27.3%)	8 (72.7%)	N/A
	No	8 (100%)	0 (0%)	N/A
Any antiarrhythmic					0.005
Yes		2 (22.2%)	7 (77.8%)	0.032 (0.002–0.426)
No		9 (90%)	1 (10%)	1.000

Laboratory findings on patients' clinical outcomes

Laboratory parameters	Reference Values	Pregnancy Effect	Outcomes		P Value
			Improvement (N = 11)	Death (N = 8)
Haemoglobin	12.0 – 15.0 g/dL	1.4 – 2.0 g/dL decrease	10.10±1.54	9.63±1.84	0.549
Leukocytes	4.0 – 10.0 x 103/μL	3.5 x 103/μL increase	13.51 (5.20–46.34)	33.03 (6.17–67.30)	0.032
Thrombocytes	150 – 410 x 103/μL	Slight decrease	248.74±149.46	210.00±149.57	0.584
D-Dimer	< 500.0 ng/mL	130 – 170 ng/mL	3107.46±2021.33	4248.74±2705.49	0.320
C-reactive protein	<5.0 mg/L	0.4 – 8.1 mg/L	83.71±67.60	148.03±40.38	0.031
Procalcitonin	<0.05 ng/mL	-	0.20 (0.20–0.74)	0.70 (0.20–7.13)	0.074
SGOT	0 – 31 U/L	-	36.00 (17.00–230.00)	63.00 (37.00–309.00)	0.028
SGPT	0 – 31 U/L	-	36.50 (12.00–230.00)	31.00 (22.00–379.00)	0.770
Albumin	3.2 – 4.6 g/dL	1 g/dL decrease	3.31±0.53	3.08±0.33	0.434
Urea	15 –40 mg/dL	50% decrease	22.00 (12.00–141.00)	66.00 (14.00–243.00)	0.126
Serum creatinine	0.50 –1.00 mg/dL	-	0.57 (0.41–1.38)	1.12 (0.56–7.99)	0.026
Arterial blood gas
pH	7.350 – 7.450	-	7.36±0.10	7.13±0.17	0.019
pO2	75.00 – 100.00	-	80.70 (56.00–268.00)	68.25 (57.50–118.40)	0.307
pCO2	35.00 – 45.00	25.00 – 33.00	38.70±9.06	59.67±13.53	0.007
P/F Ratio	>300	-	127.09 (70–382.86)	68.25 (57.50–118.40)	0.006

Criteria of adult COVID-19 severity classification according to the Indonesian COVID-19 Management Guidelines

Severity Level	Criteria
Mild	No evidence of pneumonia or hypoxia.
	Symptoms are limited to fever, cough, fatigue, anorexia, shortness of breath, myalgia, and/or other non-specific
	symptoms such as sore throat, nasal congestion, headache, diarrhea, nausea and vomiting, anosmia, or ageusia.
	SpO2 > 95% on room air.
Moderate	Clinical signs of pneumonia (fever, cough, dyspnea, tachypnea) with no sign of severe pneumonia.
	SpO2 ≥ 93% on room air.
Severe	Clinical signs of pneumonia (fever, cough, dyspnea, tachypnea) with at least one of the following: Respiratory rate > 30 breaths per minute, severe respiratory distress, and/or SpO2 < 93% on room air.
Critical	Patients with acute respiratory distress syndrome, sepsis and septic shock, or other conditions requiring external life support such as mechanical ventilation or vasopressor therapy.

Oxygenation support in the ICU

Variables	Outcome		OR (95% CI)	P value
	Improvement (N = 11)	Death (N = 8)
Baseline Respiratory Status
Oxygenation therapy at ICU admission				0.014
Simple mask	2 (100%)	0 (0%)	N/A
Non-rebreathing mask	0 (0%)	1 (100%)	N/A
HFNC	7 (70%)	3 (30%)	N/A
NIV	2 (100%)	0 (0%)	N/A
Ventilator	0 (0%)	4 (100%)	N/A
Oxygen saturation levels at admission to the hospital	95.45±3.05	82.63±12.99	N/A	0.027
Chest X-ray				0.013
Bilateral infiltrate >50%	4 (33.3%)	8 (66.7%)	N/A
Bilateral infiltrate <50%	7 (100%)	0 (0%)	N/A
Mechanical Ventilation
NIV (N = 8)	3 (37.5%)	5 (62.5%)	0.516 (0.916–1.353)	0.181
Invasive ventilators (N= 9)	1 (11.1%)	8 (88.9%)	N/A	<0.001
Intubation timing				<0.001
ER admission	0 (0%)	4 (100%)	N/A
Day 1–2 in ICU	1 (50%)	1 (50%)	N/A
≥ Day 3 in ICU	0 (0%)	3 (100%)	N/A
Days on ventilator support	7	6.63+3.02	N/A	N/A
Pneumothorax on ventilator	0 (0%)	1(100%)	N/A	0.421
Prone positioning				1.000
Yes	4 (57.1%)	3 (42.9%)	0.952 (0.144–6.281)
No	7 (58.3%)	5 (41.7%)	1.000

Treatments in the ICU

Treatment	Outcomes		OR (95% CI)	P
	Improvement (N = 11)	Death (N = 8)
Kidney replacement				0.031
Hemodialysis	0 (0%)	2 (100%)	N/A
CRRT	0 (0%)	2 (100%)	N/A
No	11 (73.3%)	4 (26.7%)	N/A
Any analgetic-sedation				<0.001
None given	8 (100%)	0 (0%)	N/A
1–3 medications	3 (60%)	2 (40%)	N/A
>3 medications	0 (0%)	6 (100%)	N/A
Antiviral				0.444
Remdesivir	10 (58.8%)	7 (41.2%)	N/A
Remdesivir and Oseltamivir	0 (0%)	1 (100%)	N/A
Corticosteroid				0.251
Dexamethasone	7 (63.6%)	4 (36.4%)	N/A
Methylprednisolone	0 (0%)	3 (100%)	N/A
Both	2 (66.7%)	1 (33.3%)	N/A
Anticoagulant				0.546
Yes	10 (62.5%)	6 (37.5%)	3.333 (0.246–45.109)
No	1 (33.3%)	2 (66.7%)	1.000
Tocilizumab (Actemra)				0.319
Yes	2 (33.3%)	4 (66.7%)	0.222 (0.028–1.754)
No	9 (69.2%)	4 (30.8%)	1.000
Intravenous immunoglobulin				0.421
Yes	0 (0%)	1 (100%)	N/A
No	11 (61.1%)	7 (28.9%)	N/A
Convalescent plasma				0.319
Yes	2 (33.3%)	4 (66.7%)	0.222 (0.028–1.754)
No	9 (69.2%)	4 (30.8%)	1.000

Baseline characteristics of maternal COVID-19 patients in ICU

Characteristics		Outcomes		P value
		Improvement (N=11)	Death (N=8)
Age (years)		34±5	34±3	0.911
Gestational age (weeks)		30 (22–41)	32 (5–38)	0.901
Pregnancy status at admission				1.000
Pregnant		8 (61.5%)	5 (38.5%)
Post delivery		3 (50%)	3 (50%)
COVID-19 severity				0.048
Mild		2 (100%)	0 (0%)
Severe		7 (77.8%)	2 (22.2%)
Critical		2 (25%)	6 (75%)
Length of stay (days)		9 (1–31)	10 (2–13)	0.901
Comorbidities
Nasopharyngeal cancer				0.421
	Yes	0 (0%)	1 (100%)
	No	11 (61.1%)	7 (38.9%)
Congestive heart failure				0.546
	Yes	1 (33.3%)	2 (66.7%)
	No	10 (62.5%)	6 (37.5%)
Coronary artery disease				0.421
	Yes	0 (0%)	1 (100%)
	No	11 (61.1%)	7 (38.9%)
Chronic hypertension				0.421
	Yes	0 (0%)	1 (100%)
	No	11 (61.1%)	7 (38.9%)
Obesity				0.164
	Yes	0 (0%)	2 (100%)
	No	11 (64.7%)	6 (35.3%)
Asthma				1.000
	Yes	1 (100%)	0 (0%)
	No	10 (55.6%)	8 (44.4%)
Type-2 diabetes mellitus				1.000
	Yes	2 (66.7%)	1 (33.3%)
	No	9 (56.2%)	7 (43.4%)
Tuberculous lymphadenitis				1.000
	Yes	1 (100%)	0 (0%)
	No	10 (55.6%)	8 (44.4%)

The Association between Comorbidities and Outcomes

Comorbidity	Outcomes		P value
	Improvement (N=11)	Death (N=8)
At least 1	15 (78.9%)	4 (21.1%)	0.026
None	90 (95.7%)	4 (4.3%)