The correct answer is:

A trial of awake prone positioning is acceptable during all 3 trimesters and, depending on the trimester, can be performed either in the left lateral decubitus position or the fully prone position.

Educational Objective:

Discuss awake prone positioning to relieve respiratory distress in pregnant patients with COVID-19.

Key Point:

Awake prone positioning is acceptable and feasible for pregnant and immediately post-partum patients. Depending on the patient’s pregnancy or post-partum degree of comfort, awake prone positioning can be performed in the left lateral decubitus or the fully prone position.

Awake prone positioning is only recommended for patients that do NOT meet intubation criteria (e.g. continued hypoxia despite maximum non-invasive oxygen therapy, altered mental status, or unprotected airway).

Explanation:

Prone positioning improves oxygenation in both pregnant and nonpregnant patients by increasing ventilation-perfusion matching through the recruiting of collapsed alveoli in the dorsal lungs.

Indications: The NIH COVID-19 treatment guidelines state that for both pregnant and non-pregnant patients, appropriate candidates for awake prone positioning are those who are able to adjust their position independently and tolerate lying prone or in the left lateral decubitus position and who do NOT meet intubation criteria (e.g. continued hypoxia despite maximum non-invasive oxygen therapy, altered mental status, or unprotected airway).

Contraindications: Awake prone positioning is contraindicated in patients who meet intubation criteria (editor’s note: e.g. altered mental status or unprotected airway). In other words, awake prone positioning is not an alternative to intubation, when intubation is indicated.

Awake prone positioning is also contraindicated in hemodynamically unstable patients, patients who recently had abdominal surgery, and patients who have an unstable spine.

In pregnant or postpartum (including immediately post-delivery) patients with ongoing hypoxemia, awake prone positioning is typically done for 2 hours in each position.

Proning of intubated patients: A trial of prone positioning is also recommended for intubated patients with refractory hypoxemia despite optimized oxygen therapy.

The most critical aspect is to assure that the endotracheal tube does not dislodge or slide into a main bronchus during turning.

Typically, prone positioning in intubated patients is done for 12-16 hours.

References :

National Institute of Health. Oxygenation and Ventilation | Coronavirus Disease COVID-19 (Updated June 11, 2020) (Accessed July 15, 2020)

Society for Maternal-Fetal Medicine Management Considerations for Pregnant Patients With COVID-19. Society for Maternal-Fetal Medicine Management Considerations for Pregnant Patients With COVID-19. (Published April 30, 2020) (Accessed July 15, 2020).