Dataset Information

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

ABSTRACT:

Background

Pregnant individuals are vulnerable to COVID-related acute respiratory distress syndrome (ARDS). There is a lack of high-quality evidence on whether elective delivery or expectant management leads to better maternal and neonatal outcomes.

Objective

To determine whether elective delivery or expectant management is associated with higher quality-adjusted life expectancy for a pregnant individual with COVID-19-related ARDS and their neonate.

Study design

We performed a clinical decision analysis using a patient level model in which we simulated pregnant 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 1,000 iterations for quantification of uncertainty. We simulated pregnant individuals at 32 weeks gestational age, invasively ventilated due to COVID-19-related ARDS. 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 (QALYs), summarized by the mean and 95% credible interval (CI). Maternal utilities incorporated neonatal outcomes in accordance with best practices in perinatal decision analysis.

Results

Model outputs for pregnant individuals were similar comparing elective delivery at 32 weeks' gestation to expectant management, including hospital survival (87.1% vs 87.4%), life-years (difference -0.1, 95%CI -1.4 to 1.1), and QALYs (difference -0.1, 95%CI -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%CI 3.5% to 7%), similar life-years (difference 0.9, 95%CI -0.9 to 2.8), and more QALYs (difference 1.3, 95%CI 0.4 to 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 at 30 weeks' gestation resulted in higher neonatal QALYs (1.1, 95% CI 0.1 to 2.1) despite higher long-term complications (4.3% vs. 0.5%, difference 3.7%, 95%CI 2.4 - 5.1%), or if intrauterine death or maternal ARDS mortality were more likely.

Conclusion

The decision to pursue elective delivery versus expectant management in a pregnant individual with COVID-19-related ARDS should be guided by gestational age, risk of intrauterine death, and maternal ARDS severity. For the pregnant individual, elective delivery is comparable but not superior to expectant management for gestational ages from 28 to 34 weeks. For neonates, elective delivery was superior if gestational age was 30 weeks or higher, and if the rate of intrauterine death or maternal mortality risk was high. We recommend basing the decision for elective delivery versus expectant management in a pregnant individual with COVID-19-related ARDS on gestational age and likelihood of intrauterine or maternal death.

SUBMITTER: Resende MF

PROVIDER: S-EPMC9307282 | biostudies-literature |

REPOSITORIES: biostudies-literature

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