Yoğun Bakım Ünitesinde COVID-19 Gebe Takibi
Özet
Gebelik dönemi, COVID-19 enfeksiyonunun seyri açısından yoğun bakım yatışı ve mekanik ventilasyon ihtiyacını artıran bağımsız bir risk faktörüdür. Bu süreçte hastaların klinik durumuna göre hastalık sınıflaması yapılarak takip ve tedavi süreçleri yönetilmektedir. Şiddetli seyreden olgularda erken uyarı işaretlerinin izlenmesi ve kılavuzlar doğrultusunda zamanında yoğun bakıma yatışın sağlanması kritik öneme sahiptir. Yoğun bakım takibinde multidisipliner klinik, hemodinamik ve laboratuvar monitörizasyonu standart parametrelerle sürdürülür. Oksijen tedavisinde maternal satürasyonun belirli seviyelerde tutulması hedeflenir; düşük veya yüksek akımlı oksijen tedavilerine yanıt alınamadığında noninvaziv veya invaziv mekanik ventilasyona geçilerek akciğer koruyucu ventilasyon stratejileri uygulanmalıdır. Dirençli hipoksemi varlığında pron pozisyonu veya ECMO gibi gelişmiş destek tedavileri multidisipliner bir yaklaşımla değerlendirilir. Farmakolojik tedavide deksametazon, remdesivir ve endike durumlarda profilaktik antikoagülasyon ile antibiyotikler kullanılırken, fetal güvenlik ve maternal fayda dengesi gözetilmelidir. Doğum zamanlaması ve yöntemi; gebelik haftası, hipokseminin derecesi ve maternal-fetal stabiliteye göre bireyselleştirilerek planlanır; özellikle dirençli hipoksemisi olan 32. gebelik haftası ve sonrasındaki gebelerde doğum seçeneği ön plana çıkmaktadır.
The gestational period is an independent risk factor increasing the need for intensive care admission and mechanical ventilation during COVID-19 infection. In this process, follow-up and treatment are managed by classifying the disease severity based on clinical presentation, requiring close monitoring of early warning signs and timely ICU admission. ICU management involves multidisciplinary clinical, hemodynamic, and laboratory monitoring, with target maternal oxygen saturation guided by arterial blood gas analyses. When low- or high-flow oxygen therapies fail, noninvasive or invasive mechanical ventilation is initiated using lung-protective ventilation strategies. Advanced support measures such as prone positioning or ECMO are considered via multidisciplinary collaboration in cases of refractory hypoxemia. Pharmacological management includes dexamethasone, remdesivir, and prophylactic anticoagulation with heparin, carefully balancing maternal benefit and fetal safety. Delivery timing and planning are strictly individualized based on gestational age, hypoxemia severity, and maternal-fetal stability, with delivery being particularly considered for patients at or beyond 32 weeks of gestation presenting with refractory hypoxemia.
Referanslar
Dotters-Katz S., Hughes B.L., Miller E.S.; Coronavirus (COVID-19) and Pregnancy: What Maternal-Fetal Medicine Subspecialists Need to Know; Society for Maternal Fetal Medicine; 11.23.2020
Halscott T., Vaught J.; Management Considerations for Pregnant Patients With COVID-19; Society for Maternal-Fetal Medicine; 2.2.2021
T.C. Sağlık Bakanlığı Halk Sağlığı Genel Müdürlüğü COVID-19 (SARS-CoV-2 Enfeksiyonu) Rehberi (Bilim kurulu çalışması), 14 Nisan 2020. https://covid19bilgi.saglik.gov.tr
Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395:1054-1062.
Buonsenso D., Raffaelli F., Tamburrini E., et al.; Clinical role of lung ultrasound for diagnosis and monitoring of COVID-19 pneumonia in pregnant women. Ultrasound Obstet Gynecol 2020; 56: 106.
Rollas K., Şenoğlu N.; Covid-19 Hastalarının yoğun bakım ünitesinde yönetimi. Tepecik Eğit. ve Araşt. Hast. Dergisi. 2020;30(Ek sayı):142-55 doi:10.5222/terh.2020.77044
Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med 2020
Wong AY, MacKenna B, Morton CE, et al. Use of non-steroidal anti-inflammatory drugs and risk of death from COVID-19:an OpenSAFELY cohort analysis based on two cohorts.Ann Rheum Dis 2021; 80:943
T.C. Sağlık Bakanlığı Sağlık Hizmetleri Genel Müdürlüğü Kan ve Kan Ürünleri Dairesi Başkanlığı COVID-19 immün (konva¬lesan) plazma tedarik ve klinik kullanım rehberi, Nisan 2020 https://covid19bilgi.saglik.gov.tr
Mehta P, McAuley DF, Brown M, et al. HLH Across Speciality Collaboration, UK. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020;28;395(10229):1033-1034.
Türk Dahili ve Cerrahi Yoğun Bakım Derneği COVID-19 hasta¬lığı takip önerileri, https://www.dcyogunbakim.org.tr/tdcy-covid-19-hastaligi-takip-onerileri
Kogelmann K, Jarczak D, Scheller M, et al. Hemoadsorption by CytoSorb in septic patients: a case series. Crit Care. 2017;21(1):74
Knaup H, Stahl K, Schmidt BMW, et al. Early therapeutic plas-ma exchange in septic shock: a prospective open-label non-randomized pilot study focusing on safety, hemodynamics, vascular barrier function, and biologic markers. Crit Care. 2018;22:285
COVID-19 Clinical Evidence Taskforce. Australian guidelines for the clinical care of people with COVID-19. 13.2 Magnesium sulfate. Melbourne: Australian COVID-19 Clinical Evidence Taskforce; 30 September 2021(cited 8 October 2021)
Goyal P, Choi JJ, Pinheiro LC, et al. Clinical Characteristics of Covid-19 in New York City. N EnglJ Med 2020 Jun 11;382(24):2372-4
Manuck TA, Rice MM, Bailit JL, et al. Preterm neonatal morbidity and mortality by gestational age: a contemporary cohort. Am J Obstet Gynecol 2016 Jul;215(1):103 e1- e14.
Oxford CM, Ludmir J. Trauma in pregnancy. Clin Obstet Gynecol 2009 Dec;52(4):611-29.
Tolcher MC, McKinney JR, Eppes CS,et al. Prone Positioning for Pregnant Women With Hypoxemia Due to Coronavirus Disease 2019.Obstet Gynecol 2020; 136:259.
Webster CM, Smith KA, Manuck TA. Extracorporeal membrane oxygenation in pregnant and postpartum women: a ten-year case series. Am J Obstet Gynecol MFM 2020;2:100108.
Barrantes JH, Ortoleva J, O'Neil ER, et al. Successful Treatment of Pregnant and Postpartum Women With Severe COVID-19 Associated Acute Respiratory Distress Syndrome With Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:132.
Shih E, DiMaio JM, Squiers JJ, et al. Treatment of Acute Respiratory Distress Syndrome from COVID-19 with Extracorporeal Membrane Oxygenation in Obstetric Patients. Am J Obstet Gynecol MFM 2021; :100537
Barbaro RP, MacLaren G, Boonstra PS, et al. Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. Lancet 2020; 396:1071
Covid Task Force.Coronavirus (COVID-19) and Pregnancy: What Maternal-Fetal Medicine Subspecialists Need to Know. Society for Maternal Fetal Medicine April 11, 2020. Accessed April 28, 2020
Breslin N, Baptiste C, Gyamfi-Bannerman C, et al.COVID-19 infection among asymptomatic and symptomatic pregnant women: Twoweeks of confirmed presentations to an affiliated pair of New York City hospitals. Am J Obstet Gynecol: Elsevier/Am J Obstet Gynecol-MFM; 2020.
Chen H GJ, Wang C, Luo F, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020;395(10226):809-15.
Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings. Centers for Disease Control and Prevention. 2020. Accessed April 8, 2020
Cook TM, El-Boghdadly K, McGuire B, et al. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020;10.1111/anae.15054.
