Mechanical ventilation and death in pregnant patients admitted for COVID-19: a prognostic analysis from the Brazilian COVID-19 registry score
Authors: Reis Zilma Silveira Nogueira , Pires Magda Carvalho , Ramos Lucas Emanuel Ferreira , Sales Thaís Lorenna Souza , Delfino-Pereira Polianna , Martins Karina Paula Medeiros Prado , Garbini Andresa Fontoura , Gomes Angélica Gomides dos Reis , Pessoa Bruno Porto , Matos Carolina Cunha , Cimini Christiane Corrêa Rodrigues , Rempel Claudete , Ponce Daniela , Aranha Felipe Ferraz Martins Graça , Anschau Fernando , Crestani Gabriela Petry , Grizende Genna Maira Santos , Bastos Gisele Alsina Nader , Goedert Giulia Maria dos Santos , Menezes Luanna Silva Monteiro , Carneiro Marcelo , Tolfo Marcia Ffner , Corrêa Maria Augusta Matos , Amorim Mariani Maciel de , Guimarães Júnior Milton Henriques , Durães Pamela Andrea Alves , Rosa Patryk Marques da Silva , Martelli Petrônio José de Lima , Almeida Rafaela Santos Charão de , Martins Raphael Castro , Alvarenga Samuel Penchel , Boersma Eric , Aguiar Regina Amélia Lopes Pessoa de , Marcolino Milena Soriano 
Published: January 2023

Abstract
Background
The assessment of clinical prognosis of pregnant COVID-19 patients at hospital presentation is challenging, due to physiological adaptations during pregnancy. Our aim was to assess the performance of the ABC2-SPH score to predict in-hospital mortality and mechanical ventilation support in pregnant patients with COVID-19, to assess the frequency of adverse pregnancy outcomes, and characteristics of pregnant women who died.

Methods
This multicenter cohort included consecutive pregnant patients with COVID-19 admitted to the participating hospitals, from April/2020 to March/2022. Primary outcomes were in-hospital mortality and the composite outcome of mechanical ventilation support and in-hospital mortality. Secondary endpoints were pregnancy outcomes. The overall discrimination of the model was presented as the area under the receiver operating characteristic curve (AUROC). Overall performance was assessed using the Brier score.

Results
From 350 pregnant patients (median age 30 [interquartile range (25.2, 35.0)] years-old]), 11.1% had hypertensive disorders, 19.7% required mechanical ventilation support and 6.0% died. The AUROC for in-hospital mortality and for the composite outcome were 0.809 (95% IC: 0.641–0.944) and 0.704 (95% IC: 0.617–0.792), respectively, with good overall performance (Brier = 0.0384 and 0.1610, respectively). Calibration was good for the prediction of in-hospital mortality, but poor for the composite outcome. Women who died had a median age 4 years-old higher, higher frequency of hypertensive disorders (38.1% vs. 9.4%, p < 0.001) and obesity (28.6% vs. 10.6%, p = 0.025) than those who were discharged alive, and their newborns had lower birth weight (2000 vs. 2813, p = 0.001) and five-minute Apgar score (3.0 vs. 8.0, p < 0.001).

Conclusions
The ABC2-SPH score had good overall performance for in-hospital mortality and the composite outcome mechanical ventilation and in-hospital mortality. Calibration was good for the prediction of in-hospital mortality, but it was poor for the composite outcome. Therefore, the score may be useful to predict in-hospital mortality in pregnant patients with COVID-19, in addition to clinical judgment. Newborns from women who died had lower birth weight and Apgar score than those who were discharged alive.