Case Presentation
A healthy 35-year-old pregnant woman, gravida 3, para 1, with a history of previous caesarian section 3 years back for fetal distress was brought to the emergency department (ED) by emergency medical services (EMS) at 26+3 weeks gestation with a one-day history of fever and shortness of breath. Three days ago, she had attended the adult Ambulatory Care Center (ACC) with a history of contact with COVID-19, cough and mild shortness of breath. She was apyrexic; her oxygen saturation was 99% and was systemically well. COVID-19 swabs were taken and advised home quarantine while awaiting the results. Telephone consultation was to take place within three days but advised to return to the hospital if she experiences worsening symptoms.
On admission to ED, she was tachypnea with respiratory rate (RR) of 50 breaths/min, 88% oxygen saturation (SpO2) on room air (94-100%), febrile at 38.5° C and tachycardia with a heart rate (HR) of 120 beats/min (60-100 beats/min). She was immediately transferred to the Intensive Care Unit (ICU); chest x-ray showed a typical COVID-19 presentation (Figure 1).
Her investigations showed: hemoglobin 11.0gm/dl, WBC 9.2 x10^3/uL, D-Dimer 0.39 mg/L FEU, Fibrinogen 4.7 gm/L (NR 2.0 – 4.1), LDH 334 U/L (NR 135 – 214), Myoglobin 80 ng/mL (NR 25 – 58), CRP 70.2 (NR 0 – 5), Interlukin-6 59 pg/mL (NR ≤ 7), and Albumin level 21 (NR 35 – 52). Echocardiogram was normal apart from minimal pericardial effusion and renal function and liver function tests were normal.
She was managed by MDT involving the ITU, obstetrics, and infectious disease teams. She was quickly put on CPAP high flow oxygen (Fio2) 50% which improved her oxygen saturation to 99%. She was started on tazocin (piperacillin, tazobactam), azithromycin, immune globulin, convalescent plasma, Dexamethasone, enoxaparin along with other supportive measures. Bedside ultrasound showed a viable active fetus with a regular heart rate in cephalic presentation with the anterior upper placenta and mildly reduced liquor volume. After 30 minutes, she was tachypneic up to 70bpm (12-20 b/m) and she expressed abdominal discomfort on non-invasive ventilation (NIV), hence discontinued and connected to a Non-rebreathing mask (NRBM) 15LPM. Her tachypnea came down to 50 BPM on NRBM.
On day 2 of ICU admission, she was not tolerating the NIV; she became tired; hence she was intubated and kept on mechanical ventilation. Following intubation and MDT was held and a decision was made to deliver by category 3 cesarean section (CS) in view of deteriorating maternal condition and to avoid possible sudden fetal demise. The procedure was done without complication and a baby was delivered in stable condition and transferred to the Neonatal Intensive Care Unit (NICU). His COVID-19 screening result was negative.
On day 4 of ICU admission, the patient’s oxygenation has improved, and trial extubation was carried out but failed as the patient became agitated. Her wound site was clean and healing well, post-operative hemoglobin was stable. There was minimal serosanguinous fluid in her drain which was removed.
She was successfully extubated on day 6 of hospital admission and kept on NRBM 10 LPM maintaining 98% oxygen. After extubating she was kept on NRBM alternative with HFNC for one week maintaining 95-98 % oxygen saturation. Then oxygen requirement decreased and was kept on a nasal cannula. On day 11 of ICU admission, she was mobilized out of bed and on day 12 of ICU admission she was saturating well on the nasal cannula. Ivabradine 5mg BID was added in view of tachycardia. She was discharged from ICU to home quarantine on day 13 of hospital admission. A chest X-ray before discharge showed a mild regression of the prior seen bilaterally airspace shadowing (Figure 2).