Clinical decision analysis of elective delivery vs expectant management for pregnant individuals with COVID-19–related acute respiratory distress syndrome

• Published in: American journal of obstetrics & gynecology MFM 2022-11, Vol.4 (6), p.100697-100697, Article 100697
• Main Authors: Resende, Maura H. Ferrari, Yarnell, Christopher J., D'Souza, Rohan, Lapinsky, Stephen E., Nam, Austin, Shah, Vibhuti, Whittle, Wendy, Wright, Julie K., Naimark, David M.J.
• Format: Article
• Language: English
• Subjects: acute respiratory distress syndrome; cesarean delivery; computer simulation; COVID-19; critical illness; decision analysis; neonatology; obstetrics; Original Research; pregnancy; premature birth
• ISSN: 2589-9333; 2589-9333
• DOI: 10.1016/j.ajogmf.2022.100697

Pregnant individuals are vulnerable to COVID-19–related acute respiratory distress syndrome. There is a lack of high-quality evidence on whether elective delivery or expectant management leads to better maternal and neonatal outcomes. This study aimed to determine whether elective delivery or expectant management are associated with higher quality-adjusted life expectancy for pregnant individuals with COVID-19-related acute respiratory distress syndrome and their neonates. We performed a clinical decision analysis using a patient-level model in which we simulatedpregnant individuals and their unborn children. We used a patient-level model with parallel open-cohort structure, daily cycle length, continuous discounting, lifetime horizon, sensitivity analyses for key parameter values, and 1000 iterations for quantification of uncertainty. We simulated pregnant individuals at 32 weeks of gestation, invasively ventilated because of COVID-19–related acute respiratory distress syndrome. In the elective delivery strategy, pregnant individuals received immediate cesarean delivery. In the expectant management strategy, pregnancies continued until spontaneous labor or obstetrical decision to deliver. For both pregnant individuals and neonates, model outputs were hospital or perinatal survival, life expectancy, and quality-adjusted life expectancy denominated in years, summarized by the mean and 95% credible interval. Maternal utilities incorporated neonatal outcomes in accordance with best practices in perinatal decision analysis. Model outputs for pregnant individuals were similar when comparing elective delivery at 32 weeks’ gestation with expectant management, including hospital survival (87.1% vs 87.4%), life-years (difference, −0.1; 95% credible interval, −1.4 to 1.1), and quality-adjusted life expectancy denominated in years (difference, −0.1; 95% credible interval, −1.3 to 1.1). For neonates, elective delivery at 32 weeks’ gestation was estimated to lead to a higher perinatal survival (98.4% vs 93.2%; difference, 5.2%; 95% credible interval, 3.5–7), similar life-years (difference, 0.9; 95% credible interval, −0.9 to 2.8), and higher quality-adjusted life expectancy denominated in years (difference, 1.3; 95% credible interval, 0.4–2.2). For pregnant individuals, elective delivery was not superior to expectant management across a range of scenarios between 28 and 34 weeks of gestation. Elective delivery in cases where intrauterine death or maternal mortality wer