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.