Risk factors for oxygen requirement in hospitalized pregnant and postpartum women with COVID-19

Baptista, Fernanda Spadotto; Paganoti, Cristiane Freitas; Gomez, Ursula Trovato; Peres, Stela Verzinhasse; Malbouisson, Luiz Marcelo; Brizot, Maria de Lourdes; Francisco, Rossana Pulcineli Vieira

doi:10.1016/j.clinsp.2022.100072

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Original articles • Clinics 77 • 2022 • https://doi.org/10.1016/j.clinsp.2022.100072 copy

Risk factors for oxygen requirement in hospitalized pregnant and postpartum women with COVID-19

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To identify risk factors for Oxygen (O₂) needs in pregnant and postpartum women with COVID-19.

Methods:

Prospective cohort involving pregnant women hospitalized with COVID-19 from April to October 2020. The oxygen need was analyzed regarding risk factors: demographic characteristics, clinical and laboratory parameters at hospital admission, and chest Computer Tomography (CT) findings. Poisson univariate analysis was used to estimate the Relative Risk (RR) and 95% Confidence Intervals.

Results:

145 patients, 80 who used and 65 who did not use O₂, were included. Body mass index ≥ 30, smoking, and chronic hypertension increased the risk of O₂ need by 1.86 (95% CI 1.10–3.21), 1.57 (95% CI 1.16‒2.12), and 1.46 (95% CI 1.09‒1.95), respectively. Patients who were hospitalized for COVID-19 and for obstetric reasons had 8.24 (95% CI 2.8‒24.29) and 3.44 (95% CI 1.05‒11.31) times more use of O₂ than those admitted for childbirth and abortion. Respiratory rate ≥ 24 breaths/min and O₂ saturation < 95% presented RR for O₂ requirements of 2.55 (1.82‒3.56) and 1.68 (95% CI 1.27-2.20), respectively. Ground Glass (GG) < 50% and with GG ≥ 50%, the risk of O₂ use were respectively 3.41-fold and 5.33-fold higher than in patients who haven’t viral pneumonia on CT. The combination of C-reactive protein ≥ 21 mg/L, hemoglobin < 11.0 g/dL, and lymphopenia < 1500 mm³ on hospital admission increased the risk of O₂ use by 4.97-times.

Conclusions:

In obstetric patients, clinical history, laboratory, clinical and radiological parameters at admission were identified as a risk for O₂ need, selecting the population with the greatest chance of worsening.

HIGHLIGHTS

In unvaccinated pregnant and postpartum women, any need for oxygen supply increases the risk of invasive ventilation.
Obesity, smoking and chronic arterial hypertension proved to be risk factors for the use of oxygen in pregnant and postpartum women with COVID-19.
The combination of C-reactive protein ≥ 21 mg/L, hemoglobin < 11.0 g/dL, and lymphopenia < 1500 mm on hospital admission and the presence of ground glass ≥ 50% in computer tomography increased the risk of O₂ use by 4.97 and 5.33 times respectively in pregnant and postpartum women with COVID-19.

Characteristics	O₂ use (n = 80)	No O₂ use (n = 65)	RR (95% CI)
Demographics
Maternal age, years^a a mean (standard deviation) or	31.5 (6.5)	27.7 (7.4)	1.03 (1.01‒1.05)
Body mass index^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval.	32.1 (28.71‒37.32)	28.7 (25.08‒31.23)	1.04 (1.02‒1.06)
< 25	9 (11.2)	16 (24.6)	Reference
≥ 25 < 30	18 (22.5)	23 (35.4)	1.22 (0.65-2.28)
>30	53 (66.2)	26 (40.0)	1.86 (1.10-3.21)
Smoking habit (n = 144)	10 (12.5)	2 (3.1)	1.57 (1.16‒2.12)
Blood Type (n = 142)
O type	32 (41.0)	29 (45.3)	0.92 (0.68‒1.25)
Other types	46 (59.0)	35 (54.7)
Pre-pregnancy comorbidity
Hypertension	18 (22.5)	6 (9.2)	1.46 (1.09‒1.95)
Pneumopathy	8 (10.0)	11 (16.9)	0.74 (0.43‒1.27)
Cardiopathy	5 (6.3)	3 (4.6)	1.14 (0.65‒1.99)
Diabetes	4 (5.0)	3 (4.6)	1.04 (0.54‒2.00)
Other^c c Other: reumathic disease, neurological disorders.	2 (2.5)	4 (6.2)	0.59 (0.19‒1.86)
Obstetrical history
Patient type
Puerperal	5 (6.3)	6 (9.2)	0.81 (0.42‒1.58)
Pregnant	75 (93.8)	59 (90.8)
Preeclampsia	6 (7.5)	4 (6.2)	1.09 (0.64‒1.86)
Gestational diabetes	21 (26.3)	13 (20)	1.16 (0.85‒1.59)

	O₂ use (n = 80)	No O₂ use (n = 65)	RR (95% CI)
Reason for hospitalization
Hospital admission due to delivery and abortion	3 (3.8)	28 (43.1)	Reference
Hospital admission due to obstetric reasons	10 (12.5)	20 (30.8)	3.44 (1.05‒11.31)
Hospital admission due to COVID-19	67 (83.8)	17 (26.2)	8.24 (2.8‒24.29)
COVID-19
Gestational age at onset of symptoms, weeks (n = 144)^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; ICU, Intensive Care Unit.	30.42 (25.14‒33.00)	33.57 (27.43‒37.71)	1.01 (1.00‒1.01)
Days of symptoms at admission (n = 143)^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; ICU, Intensive Care Unit.	8 (5‒10)	5 (4‒8)	1.02 (0.99‒1.05)
Symptoms
Fever	61 (76.3)	25 (38.5)	2.20 (1.48‒3.27)
Cough	73 (91.3)	34 (52.3)	3.70 (1.87‒7.32)
Odinophagy	18 (22.5)	7 (10.8)	1.39 (1.03‒1.88)
Myalgia	44 (55.0)	26 (40.0)	1.31 (0.97‒1.76)
Asthenia	29 (36.3)	5 (7.7)	1.86 (1.45‒2.37)
Coryza	22 (27.5)	29 (44.6)	0.69 (0.49‒0.99)
Diarrhea	4 (5.0)	3 (4.6)	1.04 (0.54‒2.01)
Anosmia	28 (35.0)	36 (55.4)	0.68 (0.49‒0.94)
Dysgeusia	21 (26.3)	24 (36.9)	0.78 (0.56‒1.13)
Dyspnoea	72 (90.0)	24 (36.9)	4.59 (2.41‒8.75)
Headache	29 (36.3)	28 (43.1)	0.88 (0.64‒1.19)
Fatigue	27(33.8)	5 (7.7)	1.79 (1.40‒2.30)
ICU admission	46 (57.5)	2 (3.1)	2.73 (2.07‒3.61)
Length of hospital stay, days	9 (7‒18)	4 (3‒7)	1.01 (1.00‒1.01)

	O₂ use (n = 80)	No O₂ use (n = 65)	RR (95% CI)
Clinical evaluation on admission
Heart rate^a a mean (standard deviation) or	96.5 (16.8)	92.1 (14.6)	1.01 (0.99‒1.02)
Respiratory rate^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval	26 (21‒32)	20 (18‒22)	1.03 (1.02‒1.05)
< 24	26 (32.9)	54 (83.1)	Reference
≥ 24	53 (67.1)	11(16.9)	2.55 (1.82‒3.56)
Systolic blood pressure^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval	117 (106‒130)	117 (110‒122)	1.00 (0.99‒1.01)
Dyastolic blood pressure^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval	71 (69‒81)	70 (66‒80)	1.00 (0.99‒1.01)
Body temperature^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval	36.4 (36‒36.5)	36 (36‒36.5)	1.28 (0.96‒1.72)
O₂ Saturation^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval	96 (95‒98)	98 (98‒99)	0.98 (0.97‒0.99)
≥ 95	72 (90)	64 (98.5)	Reference
< 95	8 (10)	1 (1.5)	1.68 (1.27–2.20)
Computer Tomography (n = 116)
Not COVID^c c Not Covid, Normal, consolidation, pleural effusion.	3 (3.9)	13 (32.5)	Reference
Ground Glass < 50%	48 (63.2)	27 (67.5)	3.41 (1.21‒9.60)
Ground Glass ≥ 50%	25 (32.9)	0 (0)	5.33 (1.92‒14.79)

Laboratorial evaluation on admission	O₂ use (n = 80)	No O₂ use (n = 65)	RR (95% CI)
Hemoglobin (n = 143)^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10. g/dL	11.0 (10.0‒12.0)	12.0 (10.0‒13.0)	0.88 (0.81‒0.97)
≥ 11 g/dL	46 (57.5)	47 (74.6)	Reference
< 11 g/dL	34 (42.5)	16 (25.4)	1.38 (1.04-1.82)
Leukocytes (n = 143)^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10. mil/mm³	8.42 (6.21‒10.82)	9.82 (6.33‒13.03)	1.00 (1.00‒1.00)
Lymphocytes (n = 143)^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10. mil/mm³	1.09 (0.785‒1.425)	1.36 (1.05‒1.88)	0.99 (0.99‒1.00)
≥ 1.50 mil/mm³	16 (20)	30 (46.2)	Reference
< 1.50 mil/mm³	31 (38.8)	20 (30.8)	1.75 (1.11-2.75)
< 1.00 mil/mm³	33 (41.2)	15 (23.1)	1.98 (1.27-3.07)
Neutrophils (n = 143)^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10. mil/mm³	6.870 (4.410‒9035)	7.250 (4.790‒10.670)	1.00 (1.00‒1.00)
Neutrophils/Lymphocytes (n = 143)^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	5.9 (3.82‒9.30)	5.0 (2.93‒6.71)	1.03 (1.01‒1.05)
< 4	24 (30)	24(38.1)	Reference
≥ 4 ≤ 6.8	23 (28.7)	24(28.1)	0.98 (0.65-1.47)
> 6.8	33 (41.2)	15 (23.8)	1.38 (0.98-1.93)
Platelets (n = 143)^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10. mil/mm³	224 (187.5‒268)	220 (155‒275)	1.00 (1.00‒1.00)
CRP (n = 138) mg/L ^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	66.0 (32.0‒116.0)	18.3 (7.1‒44.0)	1.005 (1.003‒1.007)
< 21 mg/L	12 (15)	33 (50.8)	Reference
≥ 21 ≤ 66.6 mg/L	28 (35)	18 (27.7)	2.28 (1.33-3.91)
> 66.6 mg/L	40 (50)	14 (21.5)	2.78 (1.67-4.62)
AST (n = 141) U/L^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	25 (19‒38)	19 (15‒27)	1.00 (1.00‒1.00)
ALT (n = 141) U/L^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	18 (13‒26)	15 (10‒22)	1.00 (1.00‒1.00)
LDH (n = 129) U/L^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	260 (197‒326)	200 (170‒251)	1.00 (1.00‒1.00)
CPK (n = 120) U/L^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	51 (30‒97)	57 (29‒87)	1.00 (0.99‒1.00)
D Dimer (n = 132) ng/mL ^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	1.199 (936‒1821)	1.675 (990‒2.316)	1.00 (1.00‒1.00)
Troponin (n = 120) ng/mL ^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	0.005 (0.004‒0.007)	0.005 (0.004‒0.007)	1.16 (0.81‒1.65)ⱡ
Creatinine (n = 140) mg/dL^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	0.52 (0.44‒0.61)	0.56 (0.48‒0.63)	0.64 (0.33‒1.24)
Urea (n = 141) mg/dL^b b median (interquartile range).RR, Relative Risk; CI, Confidential Interval; CRP, C-Reactive Protein; AST, Aspartate Aminotransferase; ALT, Alanine Aminotransferase; LDH, Lactic Dehydrogenase; CPK, Creatinophosphokinase.ⱡlog 10.	13 (11‒19)	16 (13‒19)	0.99 (0.97‒1.01)

Laboratory parameters	RR (95% CI)
CPR ≥ 21 mg/L	3.33 (1.02–10.92)
CPR ≥ 21 mg/L and Hb < 11 g/dL	3.75 (1.17–12.01)
CPR ≥ 21 mg/L and Ly < 1.5 mil/mm³	3.96 (1.38–11.34)
CPR ≥ 21 mg/L and Ly < 1.5 mil/mm³ and Hb < 11 g/dL	4.97 (1.74–14.14)

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[1] * Corresponding author. E-mail address: fernanda.spadotto@hc.fm.usp.br (F.S. Baptista).