In the Eye of the COVID-19 Storm
As COVID-19 began to sweep through New York City in early March, the Department of Obstetrics and Gynecology at NewYork-Presbyterian/Columbia University Irving Medical Center moved swiftly to initiate programs and protocols to protect patients, their babies, and staff. These included the establishment of universal screening for all pregnant patients being admitted to the hospital, creation of a Virtual COVID-19 Clinic, developing an Obstetric Intensive Care Unit to defray volume from NewYork-Presbyterian’s existing Intensive Care Units, and publishing the first scientific investigations of the virus related to OB patients in the United States.
In the article that follows, Dena Goffman, MD, Chief of Obstetrics for Sloane Hospital for Women, Department of Obstetrics and Gynecology, NewYork-Presbyterian/Columbia University Irving Medical Center, and Associate Chief Quality Officer for Obstetrics for NewYork-Presbyterian Hospital; Leslie Moroz, MD, MSc, Director of the Mothers Center and Critical Care Obstetrics Program; and Cynthia Gyamfi-Bannerman, MD, MSc, Co-Director of the Columbia University Preterm Birth Prevention Center, share their observations, experiences, recommendations for future care, and ongoing research in light of COVID-19 on behalf of their colleagues.
An Imperative in the COVID-19 Pandemic
“We started to recognize early on that women presenting to the hospital from our community may have been exposed to COVID-19,” says Dena Goffman, MD, Chief of Obstetrics for Sloane Hospital for Women, Department of Obstetrics and Gynecology, NewYork-Presbyterian/Columbia University Irving Medical Center, and Associate Chief Quality Officer for Obstetrics for NewYork-Presbyterian Hospital. “While we were telling everyone else to stay home, these women had to come in for routine care. In early March, we spent a lot of time brainstorming how to handle this, but on March 13, we had our first diagnosed case of COVID-19 in an OB patient. And then things escalated very quickly.”
“Our first OB patient diagnosed with COVID-19 was not yet due to deliver and was managed as an outpatient,” continues Dr. Goffman. “A week later, two women who were presenting for routine labor and delivery care and who were asymptomatic were screened at several points when they entered the hospital and before arriving at Labor and Delivery.”
“Our nurses went through a symptom list and the women had a temperature check. Everything was negative, normal. No complaints. No contact. No issues,” says Dr. Goffman. “Then those two women actually developed symptoms and became quite sick — one during delivery and the other while she was on our postpartum unit. They were both swabbed and had positive tests. We had been caring for them for days without precautions or PPE. This was a huge wake-up call that we could have women presenting for routine obstetric care who didn’t screen positive based on any of the screening questions and could then expose upwards of 30 staff and team members to the virus. We realized that we had to do something different and quickly. That happened on a Friday. Starting on Sunday, we began universal testing with nasopharyngeal swabs and a quantitative polymerase-chain-reaction test of all OB patients coming into Labor and Delivery.”
In a letter to the editor of The New England Journal of Medicine published on April 13, 2020, Dr. Goffman and her colleagues detailed results of the universal testing of 215 pregnant women who delivered at NewYork-Presbyterian/Columbia and NewYork-Presbyterian Allen Hospital between March 22 and April 4, 2020:
“All the women were screened on admission for symptoms of COVID-19. Four women (1.9%) had fever or other symptoms on admission, and all four women tested positive for SARS-CoV-2. Of the 211 women without symptoms, all were afebrile on admission. Nasopharyngeal swabs were obtained from 210 of the 211 women (99.5%) who did not have symptoms of COVID-19; of these women, 29 (13.7%) were positive for SARS-CoV-2. Thus, 29 of the 33 patients who were positive for SARS-CoV-2 at admission (87.9%) had no symptoms of COVID-19 at presentation.”
“With the decision to move to universal swabbing, we were identifying 13 to 15 percent of patients being admitted to Labor and Delivery who actually were COVID-19 positive that we would not otherwise have known about.”
— Dr. Dena Goffman
“We saw very quickly that the rate of asymptomatic positive patients was significant,” says Dr. Goffman. “With universal swabbing we were identifying 13 to 15 percent of patients being admitted to Labor and Delivery who actually were COVID-19 positive that we would not otherwise have known about. This was important data supporting the use of appropriate PPE and helping us to make decisions about caring for the newborn. There are also many downstream effects — the rooms you place patients in, the precautions you use. We were very glad that we had made the decision for universal screening and made it quickly so that we could put safe processes in place.”
Dr. Goffman and her colleagues have observed that pregnant women do not seem to be disproportionately sicker with COVID-19 than anyone else. “We breathed a great sigh of relief knowing we weren’t going to suddenly be seeing huge numbers of critically ill moms or worse.”
Currently the team is compiling data for additional research. “We have taken care of hundreds of women so far and have not seen a case of symptomatic vertical transmission in utero, so that’s reassuring, but we continue to follow these patients very closely,” adds Dr. Goffman. “In March, we were delivering women who had COVID-19 right before delivering. Now we are delivering women who had COVID-19 in March and are having a baby in June. We’re testing these babies, too, to make sure that the mother having had COVID-19 two months earlier doesn’t put the baby at a different risk.”
“It’s amazing what we collectively were able to accomplish over these last few months,” continues Dr. Goffman. “There was incredible collaboration from multiple disciplines required to take care of pregnant women with a new condition that we knew nothing about just a few months earlier. It was all hands on deck. We were taking care of patients. We were reviewing the literature daily. We were meeting daily. We were writing guidelines by day and manuscripts by night to inform others. We participated in New York State webinars. We were invited to other states’ perinatal quality collaboratives across the country to share what we were seeing in the hope that they might be better prepared when it got to them. And really, throughout the whole experience, all we were trying to do was our best to keep our patients safe and our team safe.”
Creating a Virtual COVID-19 Clinic
“We seemed to be seeing at the outset of the pandemic that patients, including obstetric patients, came in presenting with mild symptoms equivalent to a bad cold. Then throughout the next 10 to 14 days, there was a point where these patients became significantly worse,” says Leslie Moroz, MD, MSc, Director of the Mothers Center and Critical Care Obstetrics Program. “In circumstances where it was difficult to have close in-person follow-up with these patients, the question became, how can we have a robust plan for monitoring patients?”
For some time prior to the pandemic, staff at the Mothers Center, a program that provides comprehensive, multidisciplinary care for pregnant women with medical or surgical complications, had utilized telehealth visits for certain situations. “Within a matter of days as the pandemic unfolded, we were able to leverage the existing infrastructure to transition as much of our outpatient care as possible to telehealth, including prenatal and postpartum visits for non-infected pregnant women.”
“As patients were diagnosed, they were moved onto an obstetric COVID-positive patient list in the electronic medical record that our medical secretaries in the Virtual COVID-19 Clinic would review and then contact the patient to schedule an appointment,” says Dr. Moroz. “Our staff at the Mothers Center did a phenomenal job of making sure patients could connect with the system.”
The team responded to several situations that presented obstacles, including patient tracking, language barriers, patient outreach and technological issues, and vital sign monitoring. “Specifically, we were looking at objective parameters of health status, for example, connecting patients with a pulse oximeter to measure their heart rate and oxygen,” says Dr. Moroz. By the third week of the program, the team obtained a supply of pulse oximeters for outpatient surveillance. With no universally accepted device on the market for fetal monitoring, patients were counseled on fetal movement counting with strict precautions for decreased fetal movement.
In the first two weeks, Dr. Moroz and her Columbia colleagues had virtual visits with 67 patients who were pregnant and 2 postpartum patients. (Read: Rapid Development and Implementation of a COVID-19 Telehealth Clinic for Obstetric Patients, May 15, 2020, The New England Journal of Medicine Catalyst)
Developing an OB Intensive Care Unit
At the same time the Mothers Center staff were refining the outpatient program, they also moved quickly to develop an OB Intensive Care Unit on Labor and Delivery in collaboration with the Department of Anesthesiology. “Our mission was to keep our own critically ill obstetric patients, both COVID-19 and non-COVID-19 patients, with us on Labor and Delivery under the care of our physicians and to decant some of the ICU volume from other parts of the hospital,” says Dr. Moroz.
“Our mission was to keep our own critically ill obstetric patients, both COVID-19 and non-COVID-19 patients, with us on Labor and Delivery under the care of our physicians and to decant some of the ICU volume from other parts of the hospital.”
— Dr. Leslie Moroz
To achieve this, the team designated an existing area used for monitoring high-risk pregnant patients who require a higher level of care. “These patients often have one-to-one nursing or one-to-two nursing and are on continuous vital sign monitoring for mom or for baby,” says Dr. Moroz. “However, the area did not include the capability of caring for patients on vasoactive medications or who are intubated.”
The team established a six-bed OB-ICU comprised of three pods that could accommodate ICU-level critically ill obstetric patients, including those who required mechanical ventilation. Integrating the OB-ICU into the high-risk space on Labor and Delivery not only preserved the advantage of close proximity to the obstetrical operating rooms in case of urgent surgery for maternal or fetal indications, but also allowed the team to care for the majority of critically ill women with COVID-19 — both antepartum or postpartum.
To provide these rooms similar to this in an ICU, including high visibility and ventilator alarms, the OB-ICU was equipped with video capability to provide adequate monitoring as well as any equipment and medications that would be available in an ICU. Leadership from maternal-fetal medicine, anesthesia, nursing, NICU, critical care medicine, pediatrics, respiratory therapy, physical therapy, perfusion medicine, and pharmacy designated daily experienced personnel to staff the unit.
“Our goal was to have a plan that reached up to the highest levels of care, including ECMO,” says Dr. Moroz. “Our team applied non-invasive ventilatory support strategies in lieu of intubating patients. These included nebulizer treatments, bilevel positive airway pressure, continuous positive airway pressure therapy, and tracheal intubation. There are reasons to be very concerned about intubating patients with COVID-19. For us, the use of non-invasive strategies such as high-flow nasal oxygen in our pregnant patients, which we rarely do, was something that was incredibly helpful in this circumstance.”
The onset of the pandemic brought concerns regarding the sequelae of respiratory compromise from COVID-19. Responding rapidly to early warning signs of respiratory decompensation or worsening disease, following treatment protocols and best practices, working with interdisciplinary subspecialists, encouraging collaboration between physicians and nursing, and evaluating shortcomings in the system, were important elements in developing an effectively functioning OB-ICU that was optimized to provide the best possible outcomes for patients.
Investigating a Clinical Conundrum
Cynthia Gyamfi-Bannerman, MD, MSc, Principal Investigator of the NICHD Maternal-Fetal Medicine Units Network, spends a good portion of her time investigating clinical mysteries, primarily in the area of preterm birth. But in the first days of COVID-19, it became clear that she and her Columbia colleagues were facing another formidable challenge. “We had many, many unanswered questions and started to base our management on a small case series of 18 or 19 pregnant women from Wuhan, China. That was the world’s literature on COVID-19 in pregnancy,” says Dr. Gyamfi-Bannerman, Co-Director of the Columbia University Preterm Birth Prevention Center and Director of the Maternal-Fetal Medicine Fellowship Program.
In early March, Noelle Breslin, MD, a first-year fellow in Maternal Fetal Medicine, told Dr. Gyamfi-Bannerman that she had potentially been exposed to the virus via a diabetic patient who was admitted for an induction of labor. A complicated case, the patient ultimately required more surgical time and was intubated but could not be ventilated. “The surgical team decided to test her for COVID-19. At this point we had only seen one or two positives and each case was novel to us,” says Dr. Gyamfi-Bannerman.
Indeed, the patient, who tested positive, had exposed upwards of 20 to 30 doctors, nurses, and other staff to the virus. “Within a matter of hours, there was a second positive, a very similar situation,” says Dr. Gyamfi-Bannerman. “A woman who had undergone an induction of labor ended up delivering by cesarean. She had diabetes, preeclampsia, developed shortness of breath, and was obese as well. There’s a broad differential for shortness of breath in the postoperative obese patient with diabetes and preeclampsia. But because of the emerging pandemic, we sent off a COVID-19 test and that was also positive. Immediately, we realized that there was going to be many more positive women who didn’t have typical symptoms at the time we treated them. Neither of the two women had fever on presentation and their vital signs were monitored during the entire course of their labor. Neither presented with a low oxygen saturation, nothing that would suggest COVID-19, yet they were both positive. So, in that scenario, we encouraged Dr. Breslin to write up those cases for the first series of seven COVID-19-positive cases in pregnancy that we documented.”
“Because we knew we were at the leading edge of COVID-19 — just a few weeks behind Italy at the time, but the first to report in the United States — we thought that it was going to be very important to all of our colleagues around the country and the world to share what we were experiencing.”
— Dr. Cynthia Gyamfi-Bannerman
In a second larger series, Dr. Gyamfi-Bannerman and her colleagues published on the first 43 patients with COVID-19 infection at NewYork-Presbyterian/Columbia and NewYork-Presbyterian Allen Hospital (Read: COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals, American Journal of Obstetrics and Gynecology, April 9, 2020).
“Both of these were very early publications,” she says. “Publication on the seven was the first from the United States and then the 43 cases became the largest series in the world at the time. These women are coming in, and they’re largely asymptomatic. In the course of discovering this, our department decided to institute universal testing of pregnant women. The numbers that we found were asymptomatic were remarkable and showed us what was going on in New York City. Because we knew we were at the leading edge — just a few weeks behind Italy at the time, but the first to report in the United States — we thought that it was going to be very important to all of our colleagues around the country and the world to share what we were experiencing.”
Dr. Gyamfi-Bannerman also serves as Co-Chair of the American College of Obstetricians and Gynecologists COVID-19 Task Force, which quickly began to develop guidelines on how to manage pregnant women with COVID-19 for the obstetric community to follow. “I would share our findings at Columbia with the ACOG committee in real time, which, in turn helped to formulate national guidelines,” she says.
Another finding important for pregnancy, notes Dr. Gyamfi-Bannerman, is that while historically pregnant women in general fare worse with respiratory illnesses, such as H1N1, the flu, or pneumonia, the Columbia physicians were not seeing that with COVID-19. “We had to be very careful in the way that we framed the discussion about our findings, because we were seeing very similar results in pregnancy compared with literature from outside of pregnancy,” she says. “Ultimately, at least from the initial experience, it seems to be true that the pregnant women did similarly to women who were not pregnant. We are continuing to collect data to confirm this.”
“As immunology teaches us, we follow IgG and IgM and we understand what those antibodies mean for other viruses,” continues Dr. Gyamfi-Bannerman. “For CMV, for toxoplasmosis, we understand exposure and risk for reinfection if you have IgG. Yet while we understand that for so many diseases, we don’t understand that for COVID-19. There is an immediate need to know if antibody status relates to the potential second wave of COVID-19 infections and whether it confers immunity.”
Potentially there are additional long-term effects, adds Dr. Gyamfi-Bannerman. “We’ve had pregnant women who resolve their COVID-19 infection in the second and early third trimester and go on to term to deliver. We know that an inflammatory environment might be associated with some levels of adverse neurodevelopment. With the high levels of inflammation and the cytokine storm that we are seeing in these patients, we want to follow up their children to identify what the inflammatory environment means for them long term.”
Dr. Gyamfi-Bannerman and her colleagues are continuing to pursue long-term follow-up studies on COVID-19. “Ten or so years ago, there was very little known about late preterm birth and now that is very similar with COVID-19. As we at Columbia and NewYork-Presbyterian were at the epicenter of the pandemic, we have a great deal of information and experience to help inform the scientific and academic communities.”
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Jessica Spiegelman, MD, Nicole Krenitsky, MD, MBA, Sbaa Syeda, MD, Desmond Sutton, MD, Leslie Moroz, MD, MS. Rapid development and implementation of a COVID-19 telehealth clinic for obstetric patients. New England Journal of Medicine Catalyst. 2020 May 15. [Epub ahead of print]
Aziz A, Zork N, Aubey JJ, Baptiste CD, D’Alton ME, Emeruwa UN, Fuchs KM, Goffman D, Gyamfi-Bannerman C, Haythe JH, LaSala AP, Madden N, Miller EC, Miller RS, Monk C, Moroz L, Ona S, Ring LE, Sheen JJ, Spiegel ES, Simpson LL, Yates HS, Friedman AM. Telehealth for high-risk pregnancies in the setting of the COVID-19 pandemic. American Journal of Perinatology. 2020 May 12. [Epub ahead of print]
Breslin N, Baptiste C, Gyamfi-Bannerman C, Miller R, Martinez R, Bernstein K, Ring L, Landau R, Purisch S, Friedman AM, Fuchs K, Sutton D, Andrikopoulou M, Rupley D, Sheen JJ, Aubey J, Zork N, Moroz L, Mourad M, Wapner R, Simpson LL, D’Alton ME, Goffman D. COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals. American Journal of Obstetrics and Gynecology MFM. 2020 Apr 9;2(2):100118. [Epub ahead of print]