Discussion
Pregnancy complicated with pneumonia is not uncommon and can account for up to 1.5 percent of hospital admission among pregnant women in the USA.4 As COVID-19 is a novel virus current knowledge on pregnant women who are severely or critically ill with the virus is still evolving and information is lacking on the overall impact on her unborn child especially in cases of severe prematurity (<28 weeks gestation) which often presents a major management dilemma involving a delicate balance to ensure a good outcome for both mother and baby.
There is limited data on the course of Covid-19 on pregnancy outcome and the role played by normal immunogenic changes of pregnancy remains unclear. Some studies 5,6 have reported increased fetal and maternal morbidity and mortality, a higher rate of hospitalization and ITU admission among pregnant women compared to non-pregnant women and possibly more severe disease in late pregnancy compared to early pregnancy. While other studies have reported no significant worsening of symptoms and possible shortening of clinical course in pregnant women admitted to hospital with severe or critical COVID-19.7 One systematic review reported maternal mortality, stillbirth and neonatal mortality rate of 1.6%, 1.4% and 1.0% respectively.8 In another review of reports of 32 women with COVID-19 during pregnancy, preterm delivery occurred in 47% of hospitalized women with one case of stillbirth and one case of neonatal death.9 Our patient was 26+3 weeks at the time of admission and her only risk factor was being of Asian origin.
Pregnant women who are positive or in close contact with a confirmed or probable case of COVID-19 must be closely monitored with strict instructions on what to do if there is a worsening of their symptoms. Our patient first presented to ACC with mild symptoms following contact with COVID-19 patient. She has no systemic symptoms and examination was normal; therefore she was advised home quarantine and to report to ED if her symptoms worsen as per hospital protocol.
There is no consensus on the best form of fetal monitoring or the optimal time for delivery in those who are severely or critically ill. It is widely accepted that delivery should only be carried out for obstetric indications and mode of delivery should not be determined by the presence of COVID-19. In one case report10, fetal heart rate monitoring was carried out thrice daily for 20 minutes to detect any significant fetal abnormality.
Once our patient was intubated the MDT decision was to deliver by category 3 cesarean section as soon as all arrangements including neonatal intensive care support were in place. It was felt that by the time a significant fetal heart rate abnormality is detected on intermittent fetal heart rate monitoring it’s possible the fetus might have suffered a significant irreversible hypoxic brain injury. Secondly, our patient was managed in a dedicated COVID-19 intensive care unit located more than 30 minutes’ drive from the maternity and neonatal unit making it impossible to get the team across in time for category 1 cesarean section if there is a sudden maternal deterioration or acute fetal distress. Furthermore, the team felt that planned delivery in a calm environment would give the baby the best chance of survival and avoid the increased morbidity associated with an emergency cesarean section especially if it happened in the middle of the night. It is interesting to note that following delivery there was a significant reduction in patient oxygen required.